Provider Agreement for Non-Local Site

Affiliation with Northwestern LHRC

Name of Provider:

Name of Provider LHRC Liaison:

Name of Licensing Specialist:

Location of Requested Site(s):

1.  Is your program affiliated LOCALLY and in good standing with the Northwestern LHRC for at least 2 years?

o Yes

o No

·  Please attach the copies of the minutes (can be located on NWCSB website) to document

compliance with meeting attendance (1 meeting per year, minimum, for previous 2 years).

·  Please attach copies of annual reports, for previous two years.

2.Is there manager/supervisor from the agency’s non-local site accessible in person to the committee if requested?

o Yes

o No

·  Please attach a business card, or other published agency material, with contact information, to include the name of the manager/supervisor, contact phone number, and email address

3.Can your program provide technology (i.e. Skype, Lync, etc.) necessary to ensure that any client who is not local to the area can participate in regular meetings (if they desire), or special hearings (if warranted),via online networking?

o Yes

o No

·  Please reference the technology to be utilized:

4.Can your program ensure that any client who is not local to the area be transported (at the cost of the affiliated organization) to the local meeting for hearings, appeals, or attendance (if desired by the client)?

o Yes

o No

·  Please include a review of this assurance, including the offer to transport and a schedule of meetings, in the annual notification of human rights to your clients.

·  Please assure that you will provide ongoing reminder of meetings and offers to transport for each scheduled meeting of the LHRC

·  Provide a copy of the annual notification updated with this information to the committee.

·  If requested, you must provide a copy of the signed assurance(s) to the LHRC for specific clients who require this accommodation.

5.Is your program currently licensed and in good standing in Licensing Region I?

o Yes

o No

·  Please submit a copy of your current license with annual report and/or affiliation request, whichever comes first.

As the LHRC liaison, I understand and agree to the following:

1.  Sites located outside of the traditional coverage area must affirm the above criteria to gain affiliation with Northwestern LHRC. If the above guidelines are not affirmed, the requesting agency will not be granted Northwestern LHRC affiliation for the requested site.

2.  Failure to ensure and provide for the guidelines above will result in the agency losing all site affiliations located outside of the traditional coverage area with the Northwestern LHRC for the period of 1 year.

LHRC Liaison Signature Date