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This field is for validation purposes and should be left unchanged.

Agency Contact Name*

First Last

Corporate Company Name*

Agency DBA Name (if applicable)

Agency Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address, if different from above

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Website*

Date the agency opened or will open (i.e. able to accept clients)*

Number of Caregivers*

Promo Code (optional)

Membership Advisor (optional)

Community that your agency will serve (check all that apply)

Private pay
Medicaid

Qualified Agency Personnel

Name of person on staff or affiliated with the agency*

For example: Gerontologist, Social Worker, Certified Senior Advisor (CSA), R.N. etc

Has the owner or person associated with the agency have more than one year in the home care industry*

Yes
No

Agency Procedures

Percent of care that is non-medical*

Caregivers are proficient in the language of the population being served*

Yes
No

Are 90% of the agency caregivers W-2 employees*

Yes
No

Is your agency licensed by the state?*

Yes
No

Background Checks

Do all caregivers undergo a multi-tiered comprehensive local and national background check? (HCSB requirements preclude the hire of caregivers convicted of either a felony(s) or misdemeanor theft, abuse, forgery, neglect or financial malfeasance.)*

Yes
No

Acknowledgement

Does your agency carry liability insurance coverage at a minimum of $1,000,000?*

Yes
No

Does your agency carry Worker’s Compensation if required by your state?*

Yes
No

Education and Training

All agency caregivers are well trained (HCSB minimum of (12) courses or (8) hours of continuing education before providing care and updated annually).*

Yes
No

Agency Complaint Procedure

Agency has a complaint resolution policy and maintains a log of complaints and outcomes.*

Yes
No

Disclosure Questionnaire

Has any owner(s) or active manager(s) of your agency ever been convicted of a felony?*

Yes
No

Has any owner(s) or active manager(s) currently, or within the past 7 years, been a defendant or respondent in any legal or criminal proceeding relating to professional or business conduct, or currently named as a party in such action?*

Yes
No

Within the last 7 years, has any owner(s) or active manager(s) been a defendant or respondent in a civil action including, but not limited to, lawsuit, arbitration, or mediation relating to your professional or business conduct, or are you currently named as part in any such action?*

Yes
No

Provide an explanation for any “yes” answers:*

Application Disclosure and Payment Information

Payment: Upon approval of your application for A+ Certification, your ACH transfer will be charged the monthly fee of $219. As soon as you’ve successfully completed this A+ Certification process and your payment is confirmed, you’re A+ Certification will go into effect. Your agency will receive the marketing items for approval and the link to your full landing page on the HCSB’s website. HCSB reserves the right to adjust our offerings and pricing at any time, and will provide agencies with advance electronic written notice of any changes.

Cancellation:Cancellation of your A+ Certification during the first 12 months of membership requires 90 days written notice. After the first 12 months of membership, cancellation requires 30 days written notice. The HCSB also requires the return of all marketing materials (physical and electronic) before any cancellation can be processed.

Verification: As the authorized representative of this agency applying for A+ Certification and enrollment, I certify that any and all information provided here is true and correct, and acknowledge that all information is subject to review and verification. I also acknowledge that A+ Certification is granted only upon verification of meeting HCSB standards.