List of Credentialing Documents Required for Wisconsin:
Company Documents
- National Provider ID Number (Register here)
- Disclosure of Ownership - Corporate (Form Attached)
- Drug Free Workplace Statement (Form Attached)
- Acknowledgement of Company policies (Attached)
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- Maintenance of documentation for 10 years
- Attestation of LEIE, SAM, EPLS exclusion
- Driver Identification
- Daily Vehicle Inspection
- English Language Communication
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- W9 - Corporate (Attached)
- Bank Letter Verification / Voided Check to confirm bank account information
- Direct Deposit Banking Information (Form Attached)
- Business License
- Driver List
- Vehicle List
- Veyo FWA Attestation (Form Attached)
Insurance Documents
Certificate of Auto Liability Insurance (Example Attached)
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- Please make sure that there is an "X" under the "Addl Insd" column
- It must have Veyo listed as the certificate holder. Address: 16 Hawk Ridge Circle
Lake St. Louis, MO 63367 - It must have a minimum coverage of one million dollars ($1,000,000).
- Certificate of General Liability Insurance
- Please make sure that there is an "X" under the "Addl Insd" column
- It must have Veyo listed as the certificate holder. Address: 16 Hawk Ridge Circle
Lake St. Louis, MO 63367 - It must have a minimum coverage of one million dollars ($1,000,000).
- Commercial Auto and General Insurance Endorsement (Example Attached)
- Veyo will require an endorsement for both Auto Liability and General Liability
- It must have Veyo listed as the additional insured. Address: 16 Hawk Ridge Circle
Lake St. Louis, MO 63367
- Workers Compensation
- Worker's Compensation in line with the state standards.
Driver Documents
- Complete Driver List (Attached)
- Current Driver's License
- Background Check - with no felony convictions
- Must be completed by an approved agency and sent directly to Veyo by the BGC agency.
- Motor Vehicle Record
- Drug Screen (to be directly sent to Veyo by agency)
- Driver Compliance Communication (Attached)
- Driver Demographic Information - Must be Added to OurRecords
Training Requirements
*Copies of Certificates must be provided for each driver
- CPR Training Certification (Active Certification issued by a licensed Instructor)
- First Aid Training Certification (Active Certification issued by a licensed Instructor)
- Credentialing and Annual Driver Training Certification (Attached)
Vehicle Documents
- Vehicle List (Attached)
- Vehicle Insurance Card
- Vehicle Registration
- Vehicle Data - Must be Added to OurRecords
- Vehicle Inspection - Completed by Veyo (Attached)
SMV & Ambulance Enrollment Link with Forward Health
https://www.forwardhealth.wi.gov/WIPortal/Subsystem/Certification/EnrollmentCriteria.aspx