Please fill out the below application as completely as possible.

Organization Information
Organization Name:				Years in business:
Primary Contact:				# of locations:
Organization Address:				# of beds:
City, State, Zip:		, .		Average Census:
Organization Type:		Adoption Assisted Living Association Behavioral Collaboration/Training Corrections Counseling Eating Disorders Ed Inst Foster Care Gov't Sub-con Government Handicapped Home Care Hospice Independent Living Outpatient Pharmacy Pharmacy - Cardinal LTC Pharmacy - Cardinal Retail Pharmacy - Non-Cardinal Recovery Retail Skilled Nursing Troubled Youth Women's Shelter Other		Current Census:
Phone:				Parent Company:
Owners Names:				Parent Phone:
Staff Information
Total # of employees:				Total # of RNs:
Full time employees:				Full time RNs:
Part time employees:				Part time RNs:
Avg. years of staff experience:
% of Staff Turnover:		<10% 10-20% 20-40% 40-60%		% of Staff ESL (English as a Second Language)		<10% 10-20% 20-40% 40-60%
Employee Computer Competancy		Very Capable Capable Somewhat Capable Incapable
Insurance Information
Limits of Liability:				Retro Date(if claims made):
Current Insurance Company:				Premium:
Effective Date:				Deductible per claim:
Upon applying for insurance, have you ever been denied?		No Yes		Have you ever been forced to drop an already existing insurance policy for any reason?
Organization Details
Client age range:				Avg. occupancy:
Current pharmacy:				Avg. scripts/bed:
Contract w/ pharmacy:		No Yes		Est. % male clients:
Pharmacy contract expiration date:				Est. % female clients:
Med packaging:
Source of clients:		Direct sales Current client Web marketing TV/Radio Convention/Conf Word of mouth State adjudicated Other		Ever failed state inspection?:		No Yes
# of complaints (last 2 years):				Reasons failed:
Explain:				Plans for future growth:
Medical Supply/Equipment Detail
1.				Percentage:		%
2.				Percentage:		%
Monthly supply sales volume:				Is your billing outsourced?		Yes
Is your therapy business?		Outsource In-house		Are you under contract?		No Yes
If so, to whom?				Contract expire date:
Under contract?		No Yes		Are you willing to explore other options?		No Yes
If so, when does it expire?				Do you have a satisfaction survey?		No Yes
Would you consider other options?		No Yes		If yes, what type?		Mailer Personal
				upgrading?		No Yes
Submit Application
Are you willing to be on the BlueStep fast track ?		No Yes		Rep.:

 
Due to the heavy BlueStep demand and waiting list all applicants will be reviewed and considered in the same order their application was recieved.