Application- Industry Member (Placement Agents Only) Industry Member Application (Placement Agents Only) Company InformationThe information below will be used for PASRS Administrative purposes.Today's Date Company Name:*D/B/A Company NameDoes the company have a d/b/a or a different name known to customers?YesNoIf yes, what is it?Contact Person's Name* First Last Mailing AddressThe address where you'd like to receive any PASRS communications. Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Main Phone NumberMobileFaxOther PhonePlease describe this phone number's purposeEmail WebsiteCounties ServedPlease select all that apply.MaricopaPimaPinalYavapaiCoconinoYumaSanta CruzCochiseLa PazGilaGrahamGreenleeMohaveNavajoApacheDescription of Services & Specialties*Please explain any specialties or focus areas of your business. Use this space to help illustrate how your company stands apart from others in the same field. Liability Insurance*Does your business maintain professional liability insurance? Yes No Please explain any plan to obtain professional liability insurance. Insurance Carrier*Please provide the name of your professional liability insurance carrier.Proof of Insurance Agreement*By typing my name below, I agree to provide PASRS with a copy of my company's proof of liability insurance (via email or fax) and list PASRS as "Additional Insured" on the company's liability insurance policy so that the PASRS office may be automatically updated regarding any changes to your policy coverage. State License # (if applicable)Type of LicenseClient Dispute Resolution Policy* Yes No Does the company have a written policy to guide how it handles disputes with clients?Copy of Dispute Resolution Policy*By typing my name below, I agree to provide PASRS with a copy of my company's Dispute Resolution Policy (via email or fax). This information is for PASRS administrative records only and will not be shared with anyone outside of that. Years in Operation*How long has the company been in business?Less than 1 year1 year2 years3 years4 years5 years5-10 years11-15 years16-20 years20+ yearsYears in Industry*How long has the company's owner/management been in the senior service industry?Less than 1 year1 year2 years3 years4 years5 years5-10 years11-15 years16-20 years20+ yearsDisciplinary Action*Have any of the company’s owners, officers, principals, or managerial employees had their license or certification revoked, suspended, or had any other disciplinary action taken against them by a licensing body? Yes No If yes, please explain Letters of Recommendation*By typing my name below, I agree to provide PASRS with three letters of recommendation (via email or fax). One must be from a client or family member of a client I have served. This information is for PASRS administrative records only and will not be shared with anyone outside of that. Billing InformationBilling Contact Information- Same or Different as Above? Same Different Billing Contact Name First Last Billing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Billing PhoneBilling Email Payment Method*Industry Member annual dues are $250. Please select a payment method. Check by MailPlease mail checks to:PASRSP.O. Box 10156Phoenix, AZ 85064 Credit Card An Invoice is Required for Company to Provide Payment Credit Card Payment OptionsPlease select your preferred credit card payment option. Request invoice to be emailed (can pay online via invoice) Will complete and submit credit care authorization form (found at bottom, left of Home Page of PASRS.org) LEGAL AND RELEASE STATEMENTS*Privacy Practices and Use of Data: The information gathered throughout the process of membership application is intended for the review of the PASRS’s staff and/or Board of Directors. Certain parts of the application, are intended to be shared publicly. Generally speaking, shared information includes marketing-type content such as: company name, provided services, location, and contact data. PASRS utilizes application information solely for the purposes of processing new applications for membership and/or to verify that a member or prospective member has necessary documents. The information collected is not shared or distributed for any other reason. By signing below, I represent that I have reviewed the PASRS Privacy Practices and agree to the terms within it. I, the undersigned, grant the Professional Association of Referral Specialists (the "Association"), and/or its authorized agents, the rights to use the information herein, as defined above, for informational, publicity, or promotional purposes without prior notification. I understand that this Information may appear in printed materials published by the Association, on the Association's website, in the Association's presentations or exhibits, in newspapers or magazines, or on television. I agree to hold the Association and its Members harmless from all claims related to the Association's or its agents' use of this Non-Confidential Business Information for these purposes. I also agree that the Association is under no obligation to me or any other party to use this Information. By my signature below, I represent that I have read and fully understand this Application for Membership Form. Application Verification Release: I hereby authorize PASRS, its agents, officers, directors, staff, or private investigators, to make inquiries, either by written communication, telephone, computer, in person or otherwise, to any current or former business associate, governmental agency, educational institution, military establishment, relative or any other persons or entities knowledgeable of backgrounds of the individuals listed on this Application as to their prior history, without limitation, their: criminal history, business records or personal background; corporate directorship/ownership, interest in business(es), nature of business of business dealings; prior claims, lawsuits, settlements; educational background, licenses, and certifications, work experience, nature of duties, performance levels; reliability, responsibility, honesty, integrity, civility, and any other measures of their character or personality. In consideration of the furnishing of any such information by any party contacted by or on behalf of the Association, I and the business entity I represent, specifically waive any confidential relationship or privacy right which may exist for my (our) benefit and completely PASRS, and the part(ies) contacted from any responsibility or liability for damages or other injuries which may occur as a result of the release or disclosure of this information. I, and the business entity I represent, agree to indemnify and hold harmless anyone involved with the conduction of this investigation of my, or the business entities, background from any and all liabilities or claims in connection therewith. Photo static, faxed or any other copy of this instrument bearing my signature shall be equally legally valid as the original. Use of PASRS' Name, Logo and Seal: Applicant understands that PASRS name, logo and seal are proprietary properties of PASRS and the use thereof is strictly limited to PASRS and its Members in Good Standing. Upon applicant being approved to be a Member in Good Standing, the new member will be granted permission to use PASRS proprietary properties, as indicated above, in their advertising materials and website for the time duration they are recognized as a Member in Good Standing with PASRS. If, for any reason, a Member loses their Member in Good Standing status with PASRS, the applicant agrees that they will immediately cease to use PASRS proprietary properties in their advertising materials and on their website until such time that their Member in Good Standing status with PASRS can be restored. Applicant Verification: I certify that to the best of my knowledge, that the information provided herein is accurate and complete. I further agree, in the event the business I represent becomes a Member of the Association that all disputes and claims, individual or severable, involving this Membership will be submitted to the Association’s Board of Directors for final resolution. The decision rendered by the Board of Directors regarding any Member dispute or claim is binding, final, and cannot be appealed. My company’s current annual financial participation in the work of PASRS is the annual membership dues and is non-refundable. The term of Industry Membership is one year commencing on the first day of the month following notification of application approval. On each anniversary of that date thereafter, the Term shall be extended for an additional year, unless it is terminated by action of the Board of Directors or the Applicant. By typing my name below, I certify and agree to the above statements. MEMBER BEST PRACTICES*The Association’s Best Practices are designed to promote honest and ethical conduct in Arizona’s senior referral industry. They are also designed to facilitate and encourage prompt reporting of law and/or regulatory violations. Universal Best Practices All PASRS Members will: 1. Maintain a business environment that fosters fairness, respect and integrity. It is the Association’s policy that its members are lawful, highly principled and socially responsible in all business practices. All members are expected to become familiar with these Best Practices and to apply these guiding principles in the daily performance of their business activities and responsibilities. 2. Operate their businesses with due diligence and professional care in accordance with professional standards and best practices. 3. Serve in the interest of their clients and business organizations in a lawful and honest manner, while maintaining high standards of conduct and character and not engage in acts discreditable to the industry or to the Association. 4. Maintain the privacy and confidentiality of information obtained in the course of their duties, unless disclosure is required by legal authority. Such information shall not be used for personal benefit or released to inappropriate parties. 5. Ensure that all employees maintain competency in the senior referral industry and other respective fields as applicable. 6. Agree to undertake only those business activities, clients, or commitments, which they can reasonably expect to service or complete in a timely manner and with professional competence. 7. Have a written client problem resolution and/or client complaint process policy in place that promptly addresses and resolves problems, issues or conflicts in a timely manner and with professional competence. PASRS Industry Members Best PracticesAll Industry (Placement Agent) Members will: 1. PASRS Industry Members will submit to and honor all of the Universal Best Practices found in Universal Best Practices Policy. 2. PASRS Industry Members submit to and honor all Medicare/Medicaid policies at hospitals and skilled nursing facilities, home health and hospice companies regarding vendor visitation, gifting and compensation for referrals. PASRS Members will not pay for or compensate for referrals from any of these companies. 3. PASRS Industry Members will utilize a written Service Agreement to be signed by client or client's legal representative when service is initiated. At a minimum, PASRS suggests the Service Agreement contain identification of the placement agency, client, description of how referral and placement services will be performed, and description of compensation arrangement. 4. In accordance with federal and state laws, no fees of any kind can be charged or accepted for residents that are already approved or accepted into the ALTCS/Medicaid program. 5. There are exceptions to be considered when ALTCS/Medicaid approved patients are placed into a facility and a room upgrade is arranged for privately, between the family/responsible party and the receiving facility. In this instance, private pay money can be subjected to an arranged referral fee. 6. PASRS Industry Members should arrange for personalized initial interviews of clients and tours of homes and facilities when possible. 7. Prior to tours of homes or facilities, PASRS Industry Members should review the most recent DHS surveys when scheduling and planning tours of homes or facilities. 8. PASRS Industry Members will not knowingly work with homes or facilities that may recover referral fees from residents or families of residents. 9. PASRS Industry Members will familiarize themselves with the Arizona Revised Statutes and Arizona Administrative Code regarding assisted living law, with particular attention paid to residency agreements, referral fees, refund policies, termination clauses, and caregiver and manager training. 10. PASRS Industry Members will not engage in the practice of moving or relocating a previously placed client for additional economic gain (known as "churning"). 11. PASRS Industry Members will attend at least 50% of monthly (6) membership meetings during calendar year. 12. PASRS Industry Members will acquire and maintain active business professional liability insurance in the amount of $1,000,000 per occurrence. Members will provide PASRS with proof of insurance at the time of membership initiation and at renewal each year. 13. PASRS Industry Members should routinely familiarize themselves with the changing landscape of homes and centers in the community they serve, so as to always aspire to bring the best resources forward to their clients. 14. PASRS Industry Members should assist the homes, centers, and residents in resolving any and all questions regarding pricing, residency agreements, furnishings, services provided, and support services that may be indicated prior to the resident moving into the facility. 15. PASRS Industry Member Agents should disclose and promote their membership with PASRS to their clients. By typing my name below, I certify: I, and the business entity I represent, have read and agree to abide by the PASRS Best Practices Agreement. I understand I am responsible for operating under these guidelines. If I, and the business entity I represent, fail to comply with this agreement, I understand disciplinary action could be taken including loss of membership. Grievance Policy*Policy It is the policy of PASRS to have a procedure and expectation that members will abide by the Best Practices set forth by the Board of Directors (the "Board"). In the event there is a question regarding adherence to these Best Practices, the Board has a policy in which a member, affiliate member, or non-member can initiate a grievance against a PASRS member. The grievance is reviewed by the Ethics Committee and the Board. As a condition of membership, members agree to abide by the recommendations made by the Ethics Committee and Board. Procedure 1) All members will submit to and sign the Grievance Policy at the time of their application form membership to PASRS. Signing the Policy designates the member's willingness to submit to the findings and recommendations of the Ethics Committee and the Board. 2) The initiator of the grievance will notify the Board of the intent to file a grievance and complete the Grievance Form. All grievances must be filed with the Board President and no action shall be taken on any grievance until the Grievance Form is filed. After the grievance is filed with the Board President, such individual will notify the members of the Ethics Committee and provide copies of all submitted documentation to Ethics Committee members. 3) The Ethics Committee will meet and review the grievance within 14 days of the filing of the grievance. The Ethics Committee will make their recommendations to the Board within 30 days after their initial meeting, unless otherwise extended by good cause. Ethics Committee recommendations shall be obtained by simple majority vote. 4) The Board will hold a hearing with the agency named in the grievance to review the findings and recommendations submitted by the Ethics Committee. Such hearing shall be held within 30 days of the Ethics Committee submitting its findings and recommendations, unless otherwise extended by good cause. At the conclusion of the hearing, the Board will vote on whether to accept the findings and recommendations of the Ethics Committee by a simple majority vote. All recommendations will be made in writing and become part of the agency file that the Board keeps on all members. 5) Grievances substantiated after votes by the Ethics Committee and the Board that involve a violation of the Best Practices of PASRS can be grounds for the termination of membership. 6) Other than the publication of recommendations discussed in Paragraph 4 or as otherwise required by law, all matters regarding grievance complaints will remain confidential to the Ethics Committee, the Board, and the agency involved. Notwithstanding this Paragraph, the party initiating the grievance shall be entitled to notice of the findings and recommendations of the Ethics Committee and the Board. 7) The purpose of this policy is to promote consistency and integrity among professionals serving Arizona's elderly population. The intention and spirit of PASRS policy is to clarify best practices and support professionals in their quest to serve Arizona's elderly. This policy is not intended as a punitive action, but rather an educational tool designed to remedy poor practices through self-regulation. 8) Every member indemnifies and holds harmless any participant of the Ethics Committee or the Board engaged in the application of this Policy for all actions taken consistent with the investigation, hearing, and resolution of any grievance. 9) This Policy may be amended from time to time to reflect the procedures necessary to achieve PASRS' goals. Prior to the adoption of any amendment to this Policy, the proposed amendment shall be made available to all PASRS members for comment. Any proposed amendment can be adopted by majority vote of the Board 30 days after publication to PASRS' membership and shall become effective 30 days thereafter. ACKNOWLEDGEMENT By typing my name below, I certify: I, and the business entity I represent, acknowledges receipt of PASRS Grievance Policy and agrees to be bound by its provisions and the recommendations of the Ethics Committee and the Board. To reduce spam, please follow the directions below to prove that you are not a robot.