Network Provider Form

EDMI Help Network Provider Application Form

Thank you for your interest in joining the EDMI Help Provider Network. We are looking to partner with high-quality service providers committed to helping injured individuals and underserved communities with compassion, efficiency, and integrity.

Section 1: Basic Information

Business or Practice Name:
Primary Contact Name:
Phone Number:
Email Address:

Business Address:

Street Address:
City:
State:
Zip Code:

Website (optional):
Social Media (optional):

Type of Service (select one or more):

Personal Injury LawyerRental Car CenterUrgent CarePhysical TherapyHealth Insurance ProviderPsychologist or CounselorFraud or Abuse Legal ServicesCar Repair ShopTowing Company
Other:

Section 2: Experience & Credentials

Years in Operation:
Business or Professional License Number:
Are you insured?
[radio* insured use_label_element "Yes" "No"]

Upload Documents:

Business License:

Proof of Insurance:

Company Logo (optional):

Section 3: Community Commitment

Do you offer bilingual or translation services?
[radio* bilingual use_label_element "Yes" "No"]

If yes, which languages?

Do you serve low-income, immigrant, or uninsured clients?
[radio* serve-community use_label_element "Yes" "No"]

Do you offer flexible payments or discounts for referred clients?
[radio* discounts use_label_element "Yes" "No"]

Are you open to co-hosting educational workshops or attending community events with EDMI Help?
[radio* cohost use_label_element "Yes" "No"]

Section 4: Referral Logistics

Preferred Method of Referral:

Phone CallEmailWeb Form

Other:

Point of Contact for EDMI Referrals:

Name:

Phone:

Email:

Section 5: Partnership Fee

Would you be willing to provide a donation or join as a subscription member?
[radio* partnership_fee use_label_element "Yes – One-time donation" "Yes – Monthly subscriber" "No – I’d prefer free listing only"]

Signature:
Date:

By submitting this application, you agree to be contacted by EDMI Help regarding partnership opportunities, community outreach, and referral engagement.