About the USHR Care Network
We believe organizations interested in partnering to provide our diagnosis-based assistance program to their patient population should reflect the communities we serve. By including and supporting diverse businesses in our care network, we create opportunity and promote innovation that enriches communities as a whole. In addition to fulfilling tax obligations, the information below will help us connect diverse organizations, investors, researchers, and other historically underrepresented groups to the care network USHR supports.
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Business Legal Name
 *
Business Legal Address
 *
Business Phone Number
 *
Business Website
 *
Your Name
 *
Your Phone Number
 *
Your Email
Instructions
Listed below are some widely used designations of diversity that can be certified. If you would like to provide certification, please submit proper documentation to PAP@USHR.org
If your business is at least 51% owned, controlled, and actively managed by any of the following, please check: *
Required
If Minority-Owned, please check: *
Required
What percent of your patient population is enrolled with a state Medicaid Plan?
 *
FAQ
How will my information be used? The name of your business, tax ID number, business address, and business type fields are necessary for completing federal 1099-MISC tax forms. If we do not have your correct information on file, the IRS can require us to withhold 28% of your payments. In addition, we will use your answers together with our other suppliers to support state-wide and local initiatives that equalize medical opportunities among underrepresented and underserved groups of people.

Why is there an "Other" option for the ownership status and minority group questions? Diversity and inclusion are ever-evolving fields that demand constant re-evaluation. If you believe that you and your business are not represented by any of the categories listed in this form, we would like to hear about it.
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