TBI FUND VENDOR APPLICATION FORM

INSTRUCTIONS: Complete the onboarding form below and sign it to be considered for providing services to the Traumatic Brain Injury Fund. All required ﬁelds must be completed before the form can be submitted. Once your completed form is received, it will be reviewed and you will be notiﬁed if you have been authorized to provide services. You may contact the TBI Fund at 1-888-285-3036, prompt #1 for questions or assistance completing the form.

Items in * are required fields.

Vendor Information

Vendor Legal Name

DBA (if applicable)

NJ START #

Vendor Address

Unit/Suite/POBox Number

Primary Contact Name

Email

Phone Number

Check here if using a third-party billing service:

Name of Billing Service

Billing Contact Name

Billing Email

Billing Phone Number

Upload Resume(s)

Upload Insurance

Participating insurance companies (check all that apply)

Please add Participating insurance company name if selected (Other)

Service Information

Number of proposed services provided by vendor Value is not selected

Service 1

Service Name-1

CPT Code

Check here if you have a license or certification required to practice or provide the(se) service(s).

Licensing Body

Credential #

Active Date (From)

Active Date (To)

Upload License(s)/Certificate(s) (If Applicable)

Service Description

Note: The TBI Fund is not an insurance provider and does not use insurance billing increments. Rates should be for the entire session and not broken down by billing increments.

Rate (Total amount per session or item)

Unit (i.e., per item, 30 or 60 min session)

Service 2

Service Name-2

CPT Code

Check here if you have a license or certification required to practice or provide the(se) service(s).

Licensing Body

Credential #

Active Dates (From)

Active Date (To)

Upload License(s)/Certificate(s) (If Applicable)

Service Description

Note: The TBI Fund is not an insurance provider and does not use insurance billing increments. Rates should be for the entire session and not broken down by billing increments.

Rate (Total amount per session or item)

Unit (i.e., per item, 30 or 60 min session)

Service 3

Service Name-3

CPT Code

Check here if you have a license or certification required to practice or provide the(se) service(s).

Licensing Body

Credential #

Active Dates (From)

Active Date (To)

Upload License(s)/Certificate(s) (If Applicable)

Service Description

Note: The TBI Fund is not an insurance provider and does not use insurance billing increments. Rates should be for the entire session and not broken down by billing increments.

Rate (Total amount per session or item)

Unit (i.e., per item, 30 or 60 min session)

Service 4

Service Name-4

CPT Code

Check here if you have a license or certification required to practice or provide the(se) service(s).

Licensing Body

Credential #

Active Dates (From)

Active Date (To)

Upload License(s)/Certificate(s) (If Applicable)

Service Description

Note: The TBI Fund is not an insurance provider and does not use insurance billing increments. Rates should be for the entire session and not broken down by billing increments.

Rate (Total amount per session or item)

Unit (i.e., per item, 30 or 60 min session)

Service 5

Service Name-5

CPT Code

Check here if you have a license or certification required to practice or provide the(se) service(s).

Licensing Body

Credential #

Active Dates (From)

Active Date (To)

Upload License(s)/Certificate(s) (If Applicable)

Service Description

Note: The TBI Fund is not an insurance provider and does not use insurance billing increments. Rates should be for the entire session and not broken down by billing increments.

Rate (Total amount per session or item)

Unit (i.e., per item, 30 or 60 min session)

I certify that the information provided in this vendor application is true and correct to the best of my knowledge, and that I agree to comply with the terms and conditions as per N.J.A.C 10:141. I understand that I must disclose the status of all other sources for which payment was requested, denied or received for any claim submitted to the NJ TBI Fund. Such sources include but are not limited to Medicaid, Medicare, Worker’s Compensation or any other private or public insurance or payer. *

Name

Date

Signature

2025.03.V1

Your session has timed out.

Click here to access the application.

DHS-DDS-TBI-2:Traumatic Brain Injury Fund Vendor Application(v1)

Vendor Information

Service Information