Dear Applicant: Division of Vocational Rehabilitation Vendor Registration Unit. Enclosures

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1 Dear Applicant: Thank you for your interest in becoming an Individual Interpreting Vendor or Group Interpreting Agency Vendor. Registration with MyFloridaMarketPlace(MFMP) and the Florida Department of Financial Services(DFS) is required before becoming eligible to provide services. Qualifications have been updated to include new nationally recognized credentialing. The Florida Registry of Interpreters for the Deaf (FRID) credentialing will be phased out by June 30, Any interpreter(s) with credentialing expiring on or before June 30, 2018 must be able to provide proof of one of the recognized credentials in order to continue providing services. Please read the application carefully, and complete in its entirety. Please , mail, or fax completed application and all required documentation to: Division of Vocational Rehabilitation Bureau of Vendor & Contracted Services 4070 Esplanade Way Tallahassee, Florida Fax Number: If you have any questions that pertain to this application, please contact Susan Coleman at , or Once registration has been approved you will receive notification, via . Upon receipt of registration approval, we recommend you contact the VR office(s) in the location(s) where you are interested in providing services, and notify them of your availability. For a list of VR offices, please visit our website at Thank you for your invaluable contribution to helping people with disabilities find and maintain their employment and enhance their independence. We look forward to working with you. Division of Vocational Rehabilitation Vendor Registration Unit Enclosures ALLISON FLANAGAN Director, Division of Vocational Rehabilitation 2 nd Floor 4070 Esplanade Way Tallahassee, FL Toll Free: FAX: TTY users dial 711 VP users connect via VRS

2 SIGN LANGUAGE INTERPRETER SERVICES APPLICATION Applicant Information MYFLORIDAMARKETPLACE (Federal Tax ID) NUMBER OR SOCIAL SECURITY NUMBER : AGENCY OR INDIVIDUAL NAME*: AUTHORIZED AGENT NAME & TITLE**: MAILING ADDRESS: REMITTANCE ADDRESS: City State Zip Code + Four Digits PRIMARY TELEPHONE NUMBER: CONTACT NAME: ADDRESS: City State Zip Code + Four Digits FAX NUMBER: CONTACT PHONE NUMBER: Vendor Status Vendor will be providing services as an: Individual Interpreting Vendor Availability Group Interpreting Agency Vendor Please complete the DVR Areas and Counties to be Served form. Check all counties where you are available to provide services. Confidentiality Interpreter(s) must adhere to the industry s accepted Code of Professional Conduct as designed by RID. In particular, confidential information shall not be used or disclosed for any purpose beyond those required for billing VR for the services. Accepted Qualifications/Credentials All interpreters providing services to VR Customers must hold current and appropriate credentials and relevant memberships. Interpreter(s) working under this Application must possess one of the following credentials: Florida Registry of the Deaf (FRID): QA Levels 1, 2 or 3. Registry of Interpreters for the Deaf (RID): CSC; IC or TC; CI or CT; NIC; NIC Advanced; NIC Master; NAD III, IV or V; RSC; or CDI. Interpreters holding Boys Town National Research Center s EIPA level o Holders of this credential will submit to VR the EIPA results once showing that testing stimulus used was the Secondary Education material and will maintain annual RID Associate membership for the duration of providing services under this application. Interpreters holding the Board for Evaluation of Interpreters (BEI) credentials. o Holders of any of the BEI credentials will additionally maintain annual RID Associate membership for the duration of providing services to VR under this application. Sign Language Interpreter Services Page 1 of 4

3 SIGN LANGUAGE INTERPRETER SERVICES APPLICATION Proof of Interpreter Qualifications Group Interpreting Agencies Group Interpreting Agencies must provide the name(s) and current credentialing of the interpreter(s) rendering services for each assignment listed on the Sign Language Interpreter Services Invoice. The Division will conduct routine monitoring of services provided to VR Customers. Agencies must be able to provide proof the interpreter(s) held current credentials and relevant membership at the time services were rendered. Individual Interpreters Individual interpreters must provide proof of current credentials and relevant membership at time of application, and on a yearly basis thereafter. Invoicing Requirements Individual Interpreting Vendors and Group Interpreting Agency Vendors must use the attached Sign Language Interpreter Services Invoice to submit billing for services to VR. Only Group Interpreter Agencies are required to provide Interpreter Name and current Credentials. Failure to submit this information may result in a delay in invoice processing. Conditions of Providing Services as a Group Interpreting Agency All interpreters employed by interpreting agencies, and who are providing services to VR Customers, must maintain current credentials and other relevant memberships. The Agency agrees to only schedule interpreters with one of the above Accepted Qualifications/Credentials. Agencies wishing to use interpreters who possess appropriate results on the EIPA instrument shall have appropriate approvals completed before the interpreting assignment. Any deviation from this requirement shall be pre-approved by VR Vendor Registration Unit prior to the interpreting assignment. Upon request by VR, the Agency agrees to and shall present proof of current credentials and relevant membership in order to maintain a current vendor registration status. Expiration Group Interpreting Agency Registration is in effect for five (5) years or until cancelled by either party or by default as determined by VR. Individual Interpreting Registration is renewed yearly based on proof of current credentials, and other relevant information; or until cancelled by either party or by default as determined by VR. Acknowledgement and Signature I hereby acknowledge I am authorized to make application on behalf of the Agency to become an approved Sign Language Interpreter provider. I further acknowledge that I have read and agree to be bound by the terms of registration outlined in this application. If approved, we agree to accept and render services to customers of the Division of Vocational Rehabilitation (VR) on a non-discriminatory basis without regard to race, color, religion, sex, national origin, age, disability, political affiliation or belief. Failure to adhere to any and all requirements under this Application may result in revocation of registration status and termination of all rights to provide sign language interpreting services to VR Customers and/or withholding of payment for any services provided to Customers during the time period the Agency was of out compliance. Signature Date Printed Name & Title *This should be the same name reflected in MFMP, and your registration with the Department of State, Division of Corporations. **The authorized agent must have the authority to sign binding documents on behalf of the Agency. Sign Language Interpreter Services Page 2 of 4

4 DOE/VR AREAS & COUNTIES WHERE SERVICES WILL BE PROVIDED Vendor Name: FEID#: Name of Authorized Representative: Signature: *Check all that apply: Area One Area Two Area Three Area Four Area Five Area Six Escambia Santa Rosa Okaloosa Walton Holmes Jackson Washington Calhoun Liberty Bay Gulf Franklin Gadsden Leon Wakulla Jefferson Madison Hamilton Taylor Suwannee Lafayette Columbia Union Gilchrist Dixie Clay St. Johns Nassau Baker Putnam Duval Alachua Bradford Levy Marion Citrus Flagler Volusia Lake Sumter Seminole Orange Osceola Brevard Polk Hardee DeSoto Highlands Indian River St. Lucie Martin Okeechobee Pinellas Hillsborough Hernando Pasco Charlotte Lee Collier Hendry Glades Manatee Sarasota Miami-Dade Monroe Area Seven Palm Beach Broward Sign Language Interpreter Services Page 3 of 4

5 SIGN LANGUAGE INTERPRETER SERVICES INVOICE Company Name Address City, State Zip VR Unit Office: Address City, State Zip *To be used for Group Interpreting Agencies only, not Individual Freelance Interpreters Grand Total: I certify, by evidence of my signature below, the above information is true and correct. Upon request by VR, I agree to submit proof the above named interpreter(s) held current credentials and relevant memberships at the time services were rendered. Failure to provide this information may result in revocation of registration status and termination of all rights to provide sign language interpreting services to VR Customers and/or withholding of payment for any services provided to Customers during the time period the Agency was out of compliance. Signature Date Printed Name and Title Sign Language Interpreter Services Page 4 of 4