Providers Intake Infomration

Providers

Thank you for partnering to provide services for people with disabilities and the low income elderly with ConnectAbility of MN.For the safety of those we service, we need information from you to: run a background check, verify state and federal exclusionary lists, insurance.

Home Modification Licenced Contractors

  • When completing the form below:
  • Complete sections A,B and C
  • Upload your Liability Insurance verification In the INVOICE portal
  • Download and complete this W-9 form and upload in INVOICE portal

Transportation Providers

  • When completing the form below:
  • Complete sections A,B and D
  • Upload your Liability Insurance verification in the INVOICE portal below
  • Download and complete this W-9 form and upload in INVOICE portal
  • You may mail your invoices to:
  • 24707 County Road 75, Saint Augusta MN 56301
  • Email your invoice to: Finance@ConnectAbilityMN.org
  • Upload your invoice to the INVOICE portal below

Chore Services Providers

  • When completing the form below:
  • Complete sections A,B and E
  • Upload your Liability Insurance verification
  • Download and complete this W-9 form and upload in INVOICE portal
  • You may mail your invoices to:
  • 24707 County Road 75, Saint Augusta MN 56301
  • Email your invoice to: Finance@ConnectAbilityMN.org
  • Upload your invoice to the INVOICE portal below

By proving my full name below, I understand that I am proving this service as an independent contractor hired by ConnectAbility of MN. I will be provided with a federal 1099 Miscellaneous Income form from ConnectAbility of MN for services rendered. ConnectAbility of MN will not withhold income tax from my fee. I understand that ConnectAbility of MN will be conducting a background check.

Service Provider’s HIPPA/CONFIDENTIALITY AGREEMENT

I acknowledge that during the course of performing my assigned service duties for a ConnectAbility of MN Client I may have access to, use, or disclose confidential health information. I hereby agree to handle such information in a confidential manner at all times during and after my employment and commit to the following obligations:

I acknowledge that during the course of performing my assigned service duties for a ConnectAbility of MN Client I may have access to, use, or disclose confidential health information. I hereby agree to handle such information in a confidential manner at all times during and after my employment and commit to the following obligations:

A. I will use and disclose confidential health information only in connection with and for the purpose of performing my assigned duties

B. I will request, obtain or communicate confidential health information only as necessary to perform my assigned duties and shall refrain from requesting, obtaining or communicating moreconfidential health information than is necessary to accomplish my assigned duties

It is understood and agreed to that the below identified discloser of confidential information may provide certain information that is and must be kept confidential. To ensure the protection of such information, and to preserve any confidentiality necessary under patent and/or trade secret laws

1. The Recipient agrees not to disclose the confidential information obtained from the discloser toanyoneunless required to do so by law.

2. This Agreement states the entire agreement between the parties concerning the disclosure of ConfidentialInformation. Any addition or modification to this Agreement must be made in writing and signed by theparties.

3. If any of the provisions of this Agreement are found to be unenforceable, the remainder shall be enforcedas fully as possible and the unenforceable provision(s) shall be deemed modified to the limited extent requiredto permit enforcement of the Agreement as a whole.

Thanking our Partners

T.320.253.0765  | Fax.320.253.6753 | Hello@ConnectAbilityMN.org
ConnectAbility of MN | 2700 1st Street North, suite 200 | Saint Cloud MN  56303

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