Provider Application

Thank you for your interest in participating in a wonderful organization that supports our troops. If you wish to become a preferred provider for C.A.R.E. please submit the application. Our goal is to have providers nation-wide. Not all applicants will be approved because we are trying to allow for a 200 mile radius of coverage for each preferred provider. The details are on the application. If you have any questions please feel free to contact us.

Companion Animal Relief Effort
121 Packerland Dr.
Green Bay, WI 54303

Clinic Name:
Clinic Address:
Contact Name:
Contact E-mail:
Primary Doctor:

The following elements outline the spirit of care and purpose and the rules for all participating providers. If you are selected to participate in C.A.R.E. you agree to review each case and help to deter any fraudulent activity by any patient/applicant. There is NO GUARANTEE that funds will be available at all times or for any parti cular case that is submitted. You may choose at any time to proceed with any work with any patient at your own cost if you wish. The C.A.R.E. board of directors will pursue donations and marketing/exposure opportunities. As a provider you agree to submit stories to the board so they can be promoted on the site and local media can be contacted in hopes they will visit your clinic and pursue the story. Suggestions from any participating clinic are welcomed and will be reviewed by the board.

Request For Reimbursement – The provider agrees to submit the patient medical records, doctor's summary, doctor's recommendation, and total cost to perform the recommended services. Please ensure the patient has submitted a patient application to your office or to C.A.R.E. We must have the patient application and the request for reimbursement to make a decision on the case.

Reimbursement Amount – The goal is to reimburse the clinic 50% of the total cost they submit. 50% reimbursement may not be possible at all times and the board will inform the clinic if a smaller reimbursement is approved and then you can make the decision to proceed with the patient. APPROVAL IS NOT GUARNTEED – IF YOU PERFORM SERVICES BEFORE SUBMITTING A REQUEST FOR REIMBURSEMENT YOU MAY HAVE TO BEAR ALL THE COSTS OF THE SERVICES YOU PERFORMED. The board will have answers to requests in a very timely manner.

Payment From C.A.R.E. – The clinic will be paid with-in two weeks of approving their request. A check will be mailed to the clinic.

Liability – C.A.R.E. is not responsible for any further care or the outcome of the care given. The clinic will have the same liability to a patient receiving C.A.R.E. that they do to their regular paying patients.

Fraudulent Applications – if C.A.R.E. suspects that fraud has been committed by a clinic C.A.R.E. will communicate with the clinic and patient to ensure all accurate information has been collected. If C.A.R.E. determines that fraud has been committed the clinic will be immediately removed as a provider and any pending payments or cases will be terminated.

200 Mile Rule – There will be one clinic approved for a geographic region. Once a clinic is approved, C.A.R.E. will make every attempt to not approve another clinic with-in a 200 mile radius of the approved clinic. If situations arise that would be close to the 200 mile rule C.A.R.E. will communicate with the approved clinic to see if approval of the applying clinic is appropriate or not.

Patients – Most applications from patients will be received by C.A.R.E. directly from the patient. If the patient is approved the clinic MUST accept the patient. The clinic may also inform the patient in need of this program and assist the patient in submitting the application for funds. If the clinic assist in this activity please enclose all clinic information mentioned above to assist C.A.R.E. in determining eligibility for funds.

Please list the service your clinic provides:

I have read this entire document and agree to participate in accordance with the rules set forth above.