PartneringPractitioner Application | Lucy’s Love Bus

Contact Name: ______

Practice Name: ______

Website: ______

Contact Email: ______

Work Address: ______

______

Business Telephone: ______cell:______

Years in Practice: ______Experience working with pediatric oncology patients? Y N

Please list any additional languages spoken: ______

Are you able to travel to patient’s home to provide services? Y N

If yes, distance up to which you will travel (in miles): ______

Partner Practitioner Check List (please include with your application):

  • Copy of professional license and any training certificates (if applicable)
  • Copy of your Liability Insurance Policy
  • Completed application and W9, and signed Partnering Practitioner Protocol
  • Please be sure to include your name, client’s first and last name, date of service, cost per session, total due, and your complete mailing address with zip code, and phone numberon each invoice.

Thank you for partnering with us to deliver comfort and quality of life to children with cancer.

Lucy’s Love Bus

PO Box 464

Amesbury MA 01913

Phone 857-277-1984 | Fax 857-277-1807

Send correspondence to:

Partnering Practitioner Protocol

Contact our Program Manager, Jackie, at to express your interest in becoming a partner of Lucy’s Love Bus (LLB).

Please send us proof of your professional liability/malpractice insurance policy. If you operate as an individual or have clients sign waivers to participate, please contact our office.

Send a copy of your license to practice if you are a massage therapist, acupuncturist, or any other licensed professional. For any other integrative therapists or yoga/art/music therapy programs, please send copies of documentation for trainings and certifications you have completed.

When an LLB child is in need of services in your area, our Program Manager will contact you.

Prior to referring a child to you, we will have obtained written medical permission from the child’s oncologist that includes a list of contraindications, if any. We can send you copies of a child’s permission for your records if needed.

We pay invoices once per month. Please be sure to list the date of service, cost per session, total due, and the full name of the child you are working with. Please always include your complete mailing address on each invoice.A sample invoice is provided and can be submitted if you do not have your own. A payment schedule is included below.

Please fill out and send a W-9 form. We need one on file for all our partnering practitioners, especially if we will pay you more than $600 in a year, and require an SSN or TIN for all new practitioners.

Each family is allocated $500 - $1,000 to be used for integrative therapies. When a family is running out of LLB funds, we will notify both you and the family to discuss next steps.

If you should ever have any concerns about an LLB child’s health, welfare, safety or situation, please contact our Director, Beecher Grogan, immediately at 978-204-8734.

Please send all info to: or Fax to 857-277-1807
PO Box 464
Amesbury, MA 01913

I have reviewed the Partnering Practitioner Protocol sheet, and hereby declare all information submitted on my behalf to Lucy’s Love Bus is true and up to date.

Signature ______Date ______

2016 Lucy’s Love Bus Payment Schedule

We pay bills once per month in order to keep our bookkeeping costs down, so our kids get as much funding as possible.
Please make sure to submit invoices by10am Easternon the following dates (the third Tuesday of each month):
January 19th
February 16th
March 15th
April 19th
May 17th
June 21st
July 19th
August 16th
September 20th
October 18th
November 15th
December 20th
We encourage invoices to be emailed whenever possible-- if you would like a Word Doc version of an invoice to easily fill out and submit monthly to LLB, please email Jackie .

You can also fax or snail mail invoices to:
Fax:857-277-1807
Lucy's Love Bus
PO Box 464
Amesbury MA 01913
Please make sure that however you opt to send an invoice, we receive it by10am Easternon the date that we are paying bills. This ensures that we can send you a check as soon as possible. If you miss the deadline for that pay session, you will be issued a check on the following pay day.
Please only send one invoice per payment period listing all dates of service between pay dates.
Each invoice should include: child's name, date(s) of session(s), cost per session, total due, who to make the check out to, and where to send it. *Your W9 must be completed to match the person/business to whom we issue the check.*

Invoice for Lucy’s Love Bus

INSERT TODAY’S DATE

Bill to:

Lucy’s Love Bus

FAX: 857-277-1807

P.O. Box 464

Amesbury, MA 01913

Client’s name:

Date of session / Cost per session

TOTAL DUE:$ ______

Please make check payable to:

INSERT NAME OR BUSINESS NAME

STREET

TOWN, STATE, ZIP

Office use only

Units of service of

CRIMINAL OFFENDER RECORD INFORMATION (CORI) ACKNOWLEDGEMENT FORM

TO BE USED BY ORGANIZATIONS CONDUCTING CORI CHECKS FOR EMPLOYMENT, VOLUNTEER, SUBCONTRACTOR, LICENSING, AND HOUSING PURPOSES.

Lucy’s Love Bus is registered under the provisions of M.G.L. c. 6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, current licensees, and applicants for the rental or lease of housing.

As a prospective or current employee, subcontractor, volunteer, license applicant, current licensee, or applicant for the rental or lease of housing, I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to to submit a CORI check for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I may withdraw this authorization at any time by providing written notice of my intent to withdraw consent to a CORI check.

FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY: Lucy’s Love Bus may conduct subsequent CORI checks within one year of the date this Form was signed by me provided, however, that must first provide me with written notice of this check.

By signing below, I provide my consent to a CORI check and acknowledge that the information provided on Page 2 of this Acknowledgement Form is true and accurate.

______SIGNATURE DATE

Please read and sign the above CORI Acknowledgement Form if practicing in or licensed in Massachusetts. Please include with your application a copy of a government-issued photo ID in addition to the necessary licenses and certifications to practice.

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