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  1. Provider  
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  2. Referral  
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  3. Practice  
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  4. Education  
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  5. License/Certification  
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  6. Insurance  
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  7. Work History  
  8. EAP Counselor  
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  9. Disability Provider  
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  10. FFD Specialist  
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  11. Provider Profile  
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  12. Attestation  
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  13. W-9  

3. PRACTICE INFORMATION
 
A. PRACTICE INFORMATION
No records are currently attached to this provider
 
B. DEMOGRAPHIC DATA: This information is for demographic reporting purposes only and will not be used for credentialing. This information may be used in the aggregate to supply data to the federal or state government as part of a government contracting process. The information will be disclosed only for the purposes stated.
If this information is applicable to your business, please answer the following questions.
Are you an employee of a professional or other corporation? Yes No
Could your business be classified as a small business, as defined the Small Business Administration?
Small Business Enterprise is defined as a corporation, partnership, sole proprietorship, or other legal entity formed for the purpose of making a profit, which is independently owned and operated, has either fewer than 100 employees or less than $1,000,000 in annual gross receipts.		 Yes No
Could your business be classified as a business owned by women, as defined by the Department of Minority Enterprises?
Women-Owned Business is defined as a business enterprise at least 50 percent of which is owned by women, or, in the case of a publicly-owned business, where at least 51 percent of the stock is owned by women.		 Yes No
Could your business be classified as a minority-owned business, as defined by the Department of Minority Enterprises?
Minority-owned Business is defined as a business enterprise that is owned and controlled by one or more socially and/or economically disadvantaged persons. Such disadvantages may arise from cultural, racial, chronic economic circumstances or background, or other similar cause.		 Yes No
If your business could be classified as a minority-owned business, which of the following categories would it fall under?
This question is optional.
Caucasian Hispanic (Mexican, Puerto Rican, Cuban, Central or South
Black (African, Jamaican or West Indian descent) American, or other Spanish culture or origin)
Native American or Alaskan Native (Persons having origins in any of the original peoples of America) Asian or Pacific Islander (persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent of the Pacific Islands)
 
  
 
 

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