United Health Hire and Placement Agency (PA/NP)
|
|
- Jared Townsend
- 3 years ago
- Views:
Transcription
1 Dear Physician Assistant / Nurse Practitioner: Thank you for your interest in United Health Hire. We are looking forward to working with you! We offer PA and NP Locum Tenens and Permanent Placement opportunities throughout the country with assignments ranging from a day or week, to several weeks, months, or even years. Locum Tenens can help you realize your professional and financial goals while visiting new places and meeting new people. Permanent Placement can offer you the opportunity to find a stable environment in which to hone your skills. Getting Started In order to credential you to work as a Locum Tenens PA / NP, the following documentation on the Credentialing Checklist is required and updated periodically. These are our requirements for the Joint Commission. In order to remain an active PA / NP Provider with us it is necessary to have these items current in your file prior to starting any assignment through us, and we will need current copies of these items as they expire. We appreciate your help in keeping your file current so we may continue to work with you. Most items will need to be updated every 24 months or when expired. Please note that some facilities may request additional background checks and credentialing such as additional records of immunizations and drug screening. We will let you know if there are additional items needed. And most importantly, we do not share your information other than for placement at facilities with your permission. What Happens Next As Locum Tenens assignments or Permanent Positions come in that match your licenses, skills, experience, certifications, and interests we will contact you to see if you are available and would like to be submitted. Welcome to United Health Hire We will help guide you through each step in the placement process. We appreciate the opportunity to work with you and look forward to partnering with you on your path to success. United Health Hire Credentialing Checklist Application Packet Application Skills Checklist Placement Agreement PA / NP Provider Handbook Acknowledgement Form References: (Completed by a Doctor, Physician Assistant or Nurse Practitioner) Letters of Recommendation written within the last 6 months are also accepted Additional Documents Needed Curriculum Vitae (CV/Resume) Copy of undergraduate and professional education diplomas Certifications: NCCPA, AANCP, BLS, ACLS, ATLS, etc. State license(s) National Practitioner Identifier (NPI) Number Malpractice insurance (you may also use our policy at a nominal hourly rate) Current Photo Print Name Page 1 of 8
2 PA / NP Application Personal Last Name First Name Middle Previous Name Nickname Social Security # NPI # Street Address Apt. # City State Zip Phone ( ) Cell ( ) Date of Birth Place of Birth City State Country Are you authorized to work in the U.S.? Yes No Sex M F Marital Status Emergency Contact Relationship Address Phone ( ) Business Name (if incorporated) Tax ID No. How did you hear about us? Journal Internet Mailer Convention Other Interest Date(s) Available Locum Tenens Permanent Placement Both Geographical Preference Preferred Hospital Size Present Salary Desired Salary Are you employed now? Yes No If so, may we inquire of your present employer? Yes No Reason for looking Certifications National Certifying Organization Certified? Yes No Date Recertified? Yes No Date National Certifying Organization Certified? Yes No Date Recertified? Yes No Date National Certifying Organization Certified? Yes No Date Recertified? Yes No Date DEA Yes No Registration # Expiration Date VetPro Yes No Date Licenses What month and year did you pass boards? State of original licensure State of License # Exp. Date State of License # Exp. Date State of License # Exp. Date State of License # Exp. Date State of License # Exp. Date State of License # Exp. Date State of License # Exp. Date State of License # Exp. Date List other pending or active licenses Malpractice Insurance Carrier Number Exp. Date Print Name Page 2 of 8
3 Education Undergraduate Education Degree Completion Year College or University City State Professional Education Degree Completion Year College or University City State Additional Education Degree Completion Year College or University City State References 1. Name Title Years acquainted PA / NPs or MDs Facility Street Address City State Zip Phone ( ) 2. Name Title Years acquainted Facility Street Address City State Zip Phone ( ) 3. Name Title Years acquainted Facility Street Address City State Zip Phone ( ) Work History List all work beginning with most recent. If working through an agency, indicate specific hospital and agency. 1. Name of Hospital Address Supervisor Name Title Month/Year Employed From To Position Held Salary Reason for leaving 2. Name of Hospital Address Supervisor Name Title Employed From To Position Held Salary Reason for leaving 3. Name of Hospital Address Supervisor Name Title Employed From To Position Held Salary Reason for leaving Print Name Page 3 of 8
4 Questions Provide complete explanations on a separate sheet for all Yes responses. 1. Do you have any physical condition which may limit or hinder your performance in the position for which you are applying? Yes No 2. Have you ever been treated for or hospitalized for drugs or alcohol or addiction or nervous condition? 3. Have you had any malpractice claims made against you? 4. Have any insurers cancelled coverage, declined coverage, refused renewal or renewed under restrictive circumstances for your professional liability coverage? 5. Have you ever been suspended, terminated, sanctioned or otherwise restricted from participating in any private, public, federal or state health insurance program (e.g., Medicare, Medicaid, Blue Shield)? 6. Are you or have you been involved in Medicare or Medicaid fraud or exclusion? 7. Have you been the object of an administrative, civil or criminal complaint or investigation regarding sexual misconduct, including a minor? 8. Are you currently under indictment for any alleged criminal activities? 9. Have you been charged with a violation of state law pertaining to controlled substance or illegal drugs or alcohol? 10. Have judgments or settlements been made against you in a professional liability or malpractice case or are claims pending? 11. Has your license to practice ever been suspended or revoked or investigated? 12. Have your staff privileges ever been denied, suspended or restricted? 13. Have you been employed as where your employment was terminated other than lay off? 14. Have you ever been convicted of a felony or misdemeanor other than a traffic violation? Declaration The facts set forth in this application for seeking a position through United Health Hire, LLC are true and complete. I understand that false statements on this application shall be considered sufficient cause for non-utilization. United Health Hire is hereby authorized to make any investigations of my personal and professional history through any agency and/or bureau or other means. United Health Hire is also authorized to investigate my ability, work records or character through inquiries and employers mentioned in this application and hereby is released along with the persons to whom inquiry is made from any and all claims and liability growing from such inquiries. I further authorize United Health Hire to release this information to any entity deemed vital. I understand that United Health Hire has the right to request a drug screen prior to and during any assignment. PA / NP Signature Date Print Name Page 4 of 8
5 PA/NP Placement Agreement This PA/NP Placement Agreement ( Agreement ) is made and entered into by and between, PA/NP, "Contractor"), and UNITED HEALTH HIRE, LLC ("Finder ). It is effective as of, 201. In consideration for the mutual covenants and promises of the undersigned parties as set forth herein, their respective performances under this Agreement, and other good and valuable consideration, the receipt and legal sufficiency of which are hereby acknowledged, Contractor and Finder agree as follows: 1. Finder shall use reasonable efforts to search for work assignments for Contractor as a Physician Assistant or Nurse Practitioner ("PA or NP") at hospitals, medical practice groups and other health care providers or facilities (individually and collectively, Facility/Group ), but does not guarantee or otherwise ensure that any such placement will be made. Finder shall also use reasonable efforts to negotiate contract rates and/or other remuneration on behalf of Contractor for such placements that are competitive in the PA/NP industry for the type of Facility/Group and geographical area where Contractor may be assigned. 2. Contractor may accept or reject any work assignment offered by Finder. Nothing in this Agreement prohibits Contractor from performing services in addition to and other than any work assignment offered by Finder, provided that Contractor also abides by the restrictive covenants in paragraph 13 below. 3. Contractor shall inform Finder of any previous or current contact that he or she has had with each such Facility/Group before Finder sends any paperwork to the Facility/Group (including but not limited to resume/cv, licenses, or references) for the purpose of placing Contractor in a position with same. 4. Contractor is solely responsible for the producing of a profit or the suffering of a loss as a result of any placement made under this Agreement, Contractor shall have sole control over the manner and means of his or her services performed for a Facility/Group as a result of such placement, subject to any terms and conditions regarding same that may be required or otherwise instituted by such Facility/Group. Contractor is not and shall not be deemed an employee of Finder for any purpose, including but not limited to any purpose that might involve federal, state or local laws or regulations concerning employment or compensation for employment. Contractor shall not be entitled to nor eligible for any benefit coverage by Finder, including but not limited to any benefit plan, insurance program, 401(k), pension or retirement plan, or other employment-related policy, program, or procedure related to benefits provided by or through Finder for its employees. In addition, Contractor shall not be covered as an employee of Finder under workers compensation laws or insurance; federal or state pension, benefits or retirement laws; or any other state, federal or local law applicable to an employee-employer relationship. 5. Contractor shall be solely and fully responsible for obtaining and maintaining all applicable insurance and licensure requirements for a PA/NP, and shall furnish to Finder and, upon request, to any Facility/Group, proof of liability insurance, current licensure by individual nursing boards, the American Association of Nurse Anesthetists ("AANA") certification or recertification, and any other documentation that may be required for Contractor to be properly licensed, insured and able to practice as a PA/NP. Contractor is also solely and fully responsible for furnishing and paying for any liability, workers compensation, health, medical, disability, life or any other form of insurance or benefit he or she may have, and for reporting any payments received as a result of any placement under this Agreement for federal, state or local taxes or other required purposes. Contractor has full and sole responsibility for paying the costs of all such insurance and licensure, and for any and all applicable federal, state and local income taxes or withholdings related to any such payments. Contractor shall and hereby does indemnify and hold harmless Finder, and any and all of its current or former officers, directors, employees, representatives, agents and insurers from any and all payments or liability for such obligations. 6. Any work assignment which is accepted by Contractor shall be performed in a professional, diligent and timely manner that reflects positively upon the professionalism and reputation of Finder in the community and health care industry. Further, Contractor shall abide by all medical and other policies, procedures, rules and regulations that might be required by any Facility/Group to which Contractor is assigned and for which he or she performs services as a result of such placement. If Contractor fails to perform in such a manner, or to complete a work assignment after having accepted the assignment, Contractor shall be regarded as having breached this Agreement. 7. Contractor is solely and fully responsible for keeping personal records of work history, expenses and wages earned on assignments referred by Finder for purposes of future licensing, credentialing, tax filings and other aspects of maintaining his or her status as a PA/NP. If Finder advances any payment to Contractor that is owed by a Facility/Group, such payment shall be considered merely a pass-through of funds and shall not in any way establish an employee/employer relationship with Finder. Print Name Page 5 of 8
6 8. Contractor shall review and abide by the Provider Handbook that Finder will issue to Contractor and which is also located on as well as sign the Provider Acknowledgement Form. Contractor agrees to provide current documents as required for PA/NP credentialing purposes and will timely comply with periodic requests by Finder for updated documentation. 9. Contractor authorizes Finder, its agents and representatives, to release any information concerning Contractor which Finder in its sole discretion determines may be material to Contractor's placement under this Agreement, and hereby waives, releases and holds harmless Finder and any Facility/Group to which such information is disclosed, from any liability related thereto. 10. If Finder places Contractor with a Facility/Group with the intent of a permanent (direct hire) position, or if such a position later develops after a placement, then Contractor agrees that all conditions of such position, including but not limited to salary, scheduling, fringe benefits, and any other terms, shall be determined solely through an agreement between the Facility/Group and Contractor. 11. The term of this Agreement shall be for an initial period of one (1) year, and shall automatically renew for successive one (1) year periods unless either party terminates this Agreement in the manner described herein. 12. Either party may terminate this Agreement at any time, with or without cause, by giving written notice to the other party subject to the restrictions and obligations contained in this Agreement. Such notice, and any other notice required by this Agreement, shall be deemed to have been given upon its being hand delivered or mailed by certified mail, return receipt requested, or sent by traceable overnight carrier, to the other party s last known business or personal address. Notwithstanding any such termination, the restrictive covenants in paragraph 13 below, and any other provision of this Agreement that helps enable the enforcement of same, shall remain in full force and effect unless Finder unilaterally terminates this Agreement within 30 days after it is signed by Contractor and before any placement under this Agreement is made. 13. During the term of this Agreement, and for a period of one (1) year immediately after its termination for any reason, Contractor shall not, directly or through any third party acting in concert with Contractor, become employed by or conduct any work for hire, or otherwise enter into a placement or services contract, for the purpose of providing PA/NP services with any Facility/Group concerning which Contractor was referred by Finder as provided for in this Agreement. In other words, the undersigned parties agree that it is the intent of this Agreement that Finder shall be the sole source for placing Contractor with each Facility/Group contacted for such purpose during the term of this Agreement and for the one-year period immediately following its termination. 14. The undersigned parties agree that the restrictive covenants in paragraph 13 above are reasonable and necessary to protect the legitimate business interests of Finder, and that any violation of such covenant will result in immediate and irreparable harm to Finder for which a remedy at law is inadequate. Upon any such breach or threatened breach, Finder shall be entitled as a matter of right to injunctive relief and to enforce the specific performance of Contractor s obligations under these provisions without having to prove actual damage to Finder or the inadequacy of a legal remedy. The rights conferred upon Finder by the preceding shall not prevent Finder from recovering any form of monetary damages or any other form of equitable relief in addition to an injunction; but the parties further agree that the determination of such damages will be unreasonably difficult and time consuming, and may not be possible with a reasonable degree of certainty. Therefore, the parties hereby stipulate and agree that a reasonable forecast of the probable loss to Finder due to such a breach is at least $12,000.00, and as a result Finder shall be entitled to recover from Contractor an amount equal to $12, as liquidated damages and not as a penalty. 15. In the event of a breach by Contractor of this Agreement, Finder may, at its election do any or all of the following: a) Terminate this Agreement; b) Demand from Contractor the immediate payment of the $12, in liquidated damages as provided for in paragraph 14 above; c) Bring any legal or other action, including but not limited to an action for damages and injunctive relief, in order to enforce its rights under this Agreement and compel Contractor to comply with his or her obligations under this Agreement; and d) Pursue such other remedies as may be available to it. 16. If legal action is brought concerning the enforcement of this Agreement, Contractor shall pay all costs and expenses, including reasonable attorneys fees as allowed by law, incurred by Finder in connection with any such action or proceeding, and with any appeal from same, which results in: (i) the enforcement of any of the agreements, covenants or provisions of this Agreement against Contractor and to the benefit of Finder; or (ii) an award of damages or injunctive relief to Finder. 17. Contractor agrees that if a situation occurs while on a work assignment referred by Finder under this Agreement which could reasonably lead to an actual or threatened malpractice lawsuit based in whole or in part upon Contractor s actions or inactions, Contractor shall provide or will ensure that proper notice is provided to Finder and all appropriate professional liability insurance Print Name Page 6 of 8
7 carriers. Contractor shall be responsible for paying the deductible amount for each such claim if any malpractice or other professional liability insurance obtained through or otherwise provided by Finder is implicated in such action. 18. Contractor shall promptly notify Finder of any changes in his or her work eligibility, or ability or availability to be placed with a Facility/Group under this Agreement, or otherwise properly perform as a PA/NP. Such changes include, but are not limited to, any physical or mental limitations; any treatment for drugs or alcohol abuse; any malpractice claims made against Contractor, any cancellation of professional liability insurance coverage; any suspension, termination, sanctions or restrictions from a private, public, federal or state health insurance program (e.g., Medicare, Medicaid, Blue Cross/Blue Shield); any judgments or settlements pending against Contractor as a result of a professional liability lawsuit; any conviction for a felony or other crime (except for minor traffic offenses); any licensure investigations or suspensions, Medicare/Medicaid fraud or exclusion; or any other actions, investigations or circumstances that may reasonably affect such work eligibility, ability or availability. 19. Contractor shall comply with all applicable policies and procedures of the Facility/Group to which he or she may be placed, including but not limited to any drug screening and confidentiality of medical information, and any requirements of the Health Insurance Portability and Accountability Act and its implementing regulations ( HIPAA ). Contractor further agrees to execute any Business Associate Agreement or other acknowledgment, waiver or release as may be required by HIPAA in order to allow the disclosure of private health information to or from such Facility/Group or Finder 20. Contractor shall comply with the policies and regulations of the Joint Commission on Accreditation of Healthcare Organizations. 21. This Agreement shall be deemed to have been made in and shall be construed in accordance with the laws of the State of North Carolina. 22. This Agreement contains the complete understanding of the parties regarding its subject matters. All prior agreements and understandings between the parties are merged within this Agreement, and superseded and replaced by it. 23. This Agreement cannot be modified or changed, except by a written instrument signed by all parties and designated as an Amendment to this Agreement. 24. If any court of competent jurisdiction declares any provision, or part thereof, of this Agreement to be invalid or unenforceable, such provision or part shall be severed and the remainder of this Agreement shall continue in full force effect as if such invalid or unenforceable provision or part had not been contained within it. IN WITNESS WHEREOF, the parties acknowledge that they have read and fully understand this PA/NP Placement Agreement, and that they sign this Agreement intending to be bound by its terms, to be effective as of the date first written above. United Health Hire, LLC Contractor Printed Name By: Dean Bauguss, Staffing Manager Date: Date: Print Name Page 7 of 8
8 Release I understand that in processing my application with United Health Hire an investigation may be made in which information is obtained through personal interviews, and a review of information held by law enforcement or other government agencies. I authorize you to verify my past employment and education, criminal records, motor vehicle records, personal references, and other job related data provided on this application, or via the interview process. I authorize appropriate individuals, companies, institutions or agencies to release information, and I release them from any liability as a result of such inquires or disclosures. A consumer report may be generated summarizing this information. I further understand and waive my right of privacy in this investigation and release and hold harmless United Health Hire from any liability. I agree that any decision to contract with me is contingent upon the results of my report and certify that all statements and answers on my application, resume, or interview are true and complete to the best of my knowledge. I understand that if any statements are false or that if information has been omitted, this will be cause for disqualification and immediate termination of my employment. If contracted, I further authorize United Health Hire to check my credit and conviction records, as needed, on a continuous basis as it relates to my work as an independent contractor with United Health Hire. I am granting United Health Hire authorization to release confidential medical information upon the request from United Health Hire clients while I am actively working at the client s facility and/or during the profiling and placement processes. I understand that United Health Hire s goal is to always provide me with a consistent level of service. If for any reason I am dissatisfied with United Health Hire s service, I am encouraged to contact the local manager to discuss the issue. United Health Hire has processes in place to resolve customer complaints in an effective and efficient manner. If the resolution does not meet my expectation, I am encouraged to call the United Health Hire corporate office at A corporate representative will work with me to resolve my concern. PA / NP Signature Date Print Name Page 8 of 8
Dear Physician Assistant / Nurse Practitioner:
Dear Physician Assistant / Nurse Practitioner: Thank you for your interest in United Health Hire. We are looking forward to working with you! We offer PA / NP Locum Tenens and Permanent Placement opportunities
More informationINDEPENDENT HEALTHCARE PROVIDER SERVICES AGREEMENT
INDEPENDENT HEALTHCARE PROVIDER SERVICES AGREEMENT This Independent Healthcare Provider Services Agreement (the Agreement ) by and between ("Provider") a licensed physician or licensed nurse/healthcare
More informationPHYSICIAN APPLICATION FOR EMPLOYMENT
PLEASE COMPLETE The Following. DATE Name Last First Middle Maiden Address City State Zip Date of Birth Place of Birth Social Security Number US Citizen Home Phone Email Address Specialty/Sub-specialty
More informationPsyBar, LLC 6600 France Avenue South, Suite 640 Edina, MN 55435 Telephone: (952) 285-9000 Facsimile: (952) 848-1798
PsyBar, LLC 6600 France Avenue South, Suite 640 Edina, MN 55435 Telephone: (952) 285-9000 Facsimile: (952) 848-1798 Updated 12/8/15 PSYBAR, L. L. C. INDEPENDENT CONTRACTOR AGREEMENT PsyBar attempts to
More informationIndependent Contractor Information CRNA
Dear Provider: Thank you for your interest in Locum Leaders, your premier locum tenens agency. Locum Leaders provides A++ rated occurrence malpractice insurance through Med Pro. Please complete this entire
More informationBUSINESS ASSOCIATE AGREEMENT
BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement (the Agreement ), is made effective as of the sign up date on the login information page of the CarePICS.com website, by and between CarePICS,
More informationAnesthesia Providers, Inc. CRNA GENERAL INFORMATION FORM. Name First Name M.I. Last Name. Address Street Address Apt. # City State Zip Code
Anesthesia Providers, Inc. CRNA GENERAL INFORMATION FORM *Please Print Name First Name M.I. Last Name Address Street Address Apt. # City State Zip Code Date of Birth / / Mo. Date Year Home Telephone -
More informationPHYSICIANS REIMBURSEMENT FUND, INC. A Risk Retention Group. APPLICATION MD & DO Locum Tenens. 1. First Name: Middle Initial: Last Name:
PHYSICIANS REIMBURSEMENT FUND, INC. A Risk Retention Group APPLICATION MD & DO Locum Tenens Applicant Information: 1. First Name: Middle Initial: Last Name: CA Medical License #: Expiration Date: Date
More informationInitial Credentialing Application: Certified Registered Nurse Anesthetist (CRNA)
Updated 1/1/2013 Specialty Surgery Center Initial Credentialing Application: Certified Registered Nurse Anesthetist (CRNA) Dear Anesthesia Provider, Thank you for your interest in providing services at
More informationEMPLOYMENT/CREDENTIALING APPLICATION
Beacon Specialized Living Services, Inc. EMPLOYMENT/CREDENTIALING APPLICATION We do not discriminate on the basis of race, color, religion, national origin, sex, age or disability. It is our intention
More informationServices Agreement Instruction Sheet
Delta-T Group POB 884 Bryn Mawr, PA 19010 Phone: 800-251-8501 FAX: 610-527-9547 www.delta-tgroup.com Services Agreement Instruction Sheet We thank you for your interest in Delta-T Group. Below please find
More informationNURSE PRACTITIONER/PHYSICIANS ASSISTANT APPLICATION GENERAL INFORMATION. Last Name First Middle. Place of Birth Social Security #
Page 1 NURSE PRACTITIONER/PHYSICIANS ASSISTANT APPLICATION GENERAL INFORMATION Last Name First Middle Place of Birth Social Security # Home Address City State Zip Office Address City State Zip DOB Emergency
More informationAPPLICATION FOR ALLIED PROFESSIONAL STAFF
Office of Medical Affairs 736 Irving Ave Syracuse NY 13210 Phone: 315-470-7646 APPLICATION FOR ALLIED PROFESSIONAL STAFF Circle appropriate category CRNA Medical Physicist Research Assistant CST/Dntal
More informationLos Angeles County Department of Mental Health Credentialing Application for Prescribing Practitioners Delivering Services to DCFS Children
Los Angeles County Department of Mental Health Credentialing Application for Prescribing Practitioners Delivering Services to DCFS Children This application is exclusively for prescribing practitioners
More informationPRACTITIONER CREDENTIALING APPLICATION Advanced Practice Nurse Prescriber, Certified Nurse Midwife, Physician Assistant
PRACTITIONER CREDENTIALING APPLICATION Advanced Practice Nurse Prescriber, Certified Nurse Midwife, Physician Assistant Prior to submitting this application it is required that you contact the Provider
More informationEverest/WFGIA New Agent Contracting Set Up Sheet
Everest/WFGIA New Agent Contracting Set Up Sheet WFG Code # Agent s Name: Address: Apt./Suite No.: Phone Number: E-Mail Address: Checklist: Completed Producer History Sheet (9511) Contract (3357) signed
More informationIndependent Contractor Agreement
Independent Contractor Agreement This Independent Contractor Agreement ("Agreement") is made and entered by and between Vehicle Inspection Pro s, LLC. ( VIP or Company"), a Missouri Limited Liability Company
More informationBusiness Associate Agreement
Business Associate Agreement This Business Associate Contract (Agreement) is entered into by and between, as a Covered Entity as defined in relevant federal and state law, and HMS Agency, Inc., as their
More informationHOUSTON LAWYER REFERRAL SERVICE, INC. RULES OF MEMBERSHIP
HOUSTON LAWYER REFERRAL SERVICE, INC. RULES OF MEMBERSHIP The Houston Lawyer Referral Service, Inc. (HLRS) is a non-profit corporation sponsored by the Houston Bar Association, Houston Young Lawyers Association,
More informationApplication for Limited Professional Liability Coverage Insured Paramedical Employee
Application for Limited Professional Liability Coverage Insured Paramedical Employee ProAssurance Indemnity Company, Inc. 1242 East Independence Street, Suite 100 Springfield, MO 65804 417.887.3120 800.492.7212
More informationELECTRONIC INDEPENDENT CONTRACTOR AGREEMENT INTRODUCTION
INTRODUCTION This is an AGREEMENT between you and Field Solutions, LLC ( Field Solutions ) that defines the terms and conditions for Field Solutions to engage you to provide services to our customers as
More informationPROVIDER APPLICATION
COMMUNITY MENTAL HEALTH AFFILIATION OF MID-MICHIGAN PROVIDER APPLICATION Thank you for your interest in becoming a provider of the Community Mental Health Affiliation of Mid-Michigan (CMHAMM) provider
More informationCRNA APPLICATION/CHECKLIST INSTRUCTIONS:
MAXIM is an equal opportunity Employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin,
More informationCLS Investments, LLC Instructions for the Solicitor Application and Agreement
CLS Investments, LLC Instructions for the Solicitor Application and Agreement Please complete all fields on page 1 of the Solicitor Application and Agreement. Some general guidelines are set forth below.
More informationGSG APPRAISAL MANAGEMENT, LLC INDEPENDENT FEE APPRAISER APPLICATION
GSG APPRAISAL MANAGEMENT, LLC INDEPENDENT FEE APPRAISER APPLICATION Thank you for your interested in joining the GSG Appraisal Management (GSG AMC) residential appraisal panel. In order to be considered
More informationSEPARATION AGREEMENT AND GENERAL RELEASE. into by and between ( Employee ) and ( the
SEPARATION AGREEMENT AND GENERAL RELEASE This Separation Agreement and General Release ( this Agreement ) is made and entered into by and between ( Employee ) and ( the Agency ) (collectively, the Parties
More informationRecitals. NOW, THEREFORE, the parties hereto agree as follows: Agreement
THIS INDEPENDENT CONTRACTOR SERVICES AGREEMENT (this Agreement ) is made this day of, 20 (the Effective Date ), regardless of the date of execution, by and between Sierra Field Services, Inc., a Nevada
More informationAllied Health Professional Liability Insurance Application Form
Allied Health Professional Liability Insurance Application Form With your fully completed, signed and dated application, you must submit the following information: 1. Current insurance policy declarations
More informationBENCHMARK MEDICAL LLC, BUSINESS ASSOCIATE AGREEMENT
BENCHMARK MEDICAL LLC, BUSINESS ASSOCIATE AGREEMENT This BUSINESS ASSOCIATE AGREEMENT ( Agreement ) dated as of the signature below, (the Effective Date ), is entered into by and between the signing organization
More informationApplication for Coverage Ancillary This application is for claims made coverage. Please read the policy carefully.
I. Employer Information Agency/Broker: Address: Application for Coverage Ancillary This application is for claims made coverage. Please read the policy carefully. Name of Employer Office Address Street
More information1. Legal Name of the Primary Applicant: 3. Corporate Contact Name: 4. Corporate Contact Phone:
PSIC RPG Association Large Group Dental Application A. APPLICANT Information 1. Legal Name of the Primary Applicant: 2. of Incorporation or Formation: MO/DAY/YR 3. Corporate Contact Name: 4. Corporate
More informationDATA USE AGREEMENT RECITALS
DATA USE AGREEMENT This Data Use Agreement (the Agreement ), effective as of the day of, 20, is by and between ( Covered Entity ) and ( Limited Data Set Recipient or Recipient ) (collectively, the Parties
More informationNow Accepting Applications for Nurse Practitioner Residency Full-Time 10 Month Appointment Starts January 9, 2012
Now Accepting Applications for Nurse Practitioner Residency Full-Time 10 Month Appointment Starts January 9, 2012 The University of California Los Angeles School of Nursing Health Center at the Union Rescue
More informationAPPLICATION FOR THERAPEUTIC MASSAGE THERAPIST LICENSE
APPLICATION FOR THERAPEUTIC MASSAGE THERAPIST LICENSE CITY ADMINISTRATOR S OFFICE 1307 Cloquet Avenue, Cloquet MN 55720 Phone: 218-879-3347 Fax: 218-879-6555 www.ci.cloquet.mn.us email: djohnson@ci.cloquet.mn.us
More informationInsurance Market Solutions Group, LLC Sub-Producer Agreement
Insurance Market Solutions Group, LLC Sub-Producer Agreement This Producer Agreement is made and entered into effective the day of, 20, by and between Insurance Market Solutions Group, LLC a Texas Company
More informationLouisiana State University System
PM-36: Attachment 4 Business Associate Contract Addendum On this day of, 20, the undersigned, [Name of Covered Entity] ("Covered Entity") and [Name of Business Associate] ("Business Associate") have entered
More informationATTORNEY-CLIENT WORKERS COMPENSTATION FEE CONTRACT AND AUTHORIZATION TO REPRESENT
STATE OF GEORGIA ATTORNEY-CLIENT WORKERS COMPENSTATION FEE CONTRACT AND AUTHORIZATION TO REPRESENT I,, with a Social Security Number of the undersigned, do hereby retain the Ramos Law Firm, LLC, located
More informationWORK PREFERENCES FORM CRNA INFORMATION PACKET SCOPE OF CLINICAL PRIVILEGES FORM PROFESSIONAL
**ALL areas must be legible and accurate. Providing complete addresses, current phone and fax numbers, and appropriate contact individuals will help expedite the credentialing process and therefore your
More informationAMERICAN INSURANCE ORGANIZATION AGENT AGREEMENT
AGREEMENT made this day of, 20, by and between American Insurance Organization, hereinafter referred to as AIO and, hereinafter referred to as Agent. The Agent is being offered the position of. RECITALS
More informationNEW ERA LIFE INSURANCE COMPANY GENERAL AGENT S CONTRACT. For. Name. Address. City State Zip
NEW ERA LIFE INSURANCE COMPANY GENERAL AGENT S CONTRACT For Name Of Address City State Zip P.O. Box 4884 Houston, Texas 77210-4884 200 Westlake Park Blvd. Suite # 1200 Houston, Texas 77079 1-800-713-4680
More informationResident Credentialing Policy Wayne State University
Resident Credentialing Policy Wayne State University REQUIREMENTS FOR INITIAL RESIDENT APPOINTMENT Residency Office Responsibilities: 1. Resident Initial Appointment Recommendation Letter: Initial applications
More information2014 NURSE PRACTITIONER RESIDENCY
2014 NURSE PRACTITIONER RESIDENCY Glide Health Services in partnership with UCSF School of Nursing and Community Health Center, Inc. APPLICATION INSTRUCTIONS Thank you for your interest in the Nurse Practitioner
More informationBUSINESS ASSOCIATE AGREEMENT
BUSINESS ASSOCIATE AGREEMENT THIS BUSINESS ASSOCIATE AGREEMENT (the AGREEMENT ) is entered into this (the "Effective Date"), between Delta Dental of Tennessee ( Covered Entity ) and ( Business Associate
More informationLast Name First Middle
P.O. Box 327 Seattle, WA 98111-0327 DENTAL PROVIDER CREDENTIALING APPLICATION This application is not a contract. The information provided in this application is used to determine whether a practitioner
More informationHOMEOWNERS LIMITED REPRESENTATIVE SERVICE AGREEMENT With SERVICE FIRST INSURANCE GROUP LLC. Of CYPRESS PROPERTY & CASUALTY INSURANCE COMPANY
HOMEOWNERS LIMITED REPRESENTATIVE SERVICE AGREEMENT With SERVICE FIRST INSURANCE GROUP LLC. Of CYPRESS PROPERTY & CASUALTY INSURANCE COMPANY This Agreement is made and entered into effective as of October
More informationPsychological Mobile Services, PA
INDEPENDENT CONTRACTOR AGREEMENT This Agreement is entered into effective as of the day of, between Psychological Mobile Services, PA (the Contractor ), and ( Independent Contractor ), (Degree, Title)
More informationDoctors Hospital Allied Health Professional Application for Appointment
Doctors Hospital Allied Health Professional Application for Appointment Applying for the following job (please check): Allied Health Delineation of Privileges Allied Health Scope of Practice Category 1
More informationADDENDUM NO. 1 TO RFP 9600-61: Locum Tenens Referrals
ADDENDUM NO. 1 TO RFP 9600-61: Locum Tenens Referrals Date: March 18, 2015 To: All Vendors Interested in RFP # 9600-61 From: Kristen Aldrich, Deputy Purchasing Agent, NMC Contracts Division Subject: Addendum
More informationNPSA GENERAL PROVISIONS
NPSA GENERAL PROVISIONS 1. Independent Contractor. A. It is understood and agreed that CONTRACTOR (including CONTRACTOR s employees) is an independent contractor and that no relationship of employer-employee
More informationNEIGHBORHOOD HEALTH PLAN OF RHODE ISLAND: SMALL BUSINESS HEALTH OPTIONS PROGRAM PRODUCER AGREEMENT
NEIGHBORHOOD HEALTH PLAN OF RHODE ISLAND: SMALL BUSINESS HEALTH OPTIONS PROGRAM PRODUCER AGREEMENT This PRODUCER AGREEMENT ( Agreement ) made effective as of the day of, 20 (the Effective Date ) is between
More informationSOLICITOR APPLICATION
Date: / / SOLICITOR APPLICATION General Information Name: Birth Date: / / Office Address: City: State: Zip: E-mail address: Business phone: ( ) - Fax number: ( ) - Assistant s Name: Registered Investment
More informationSurgical Center of Greensboro/Orthopaedic Surgical Center Div of Surgical Care Affiliates
Allied Health Staff Application Instructions We are pleased to provide you with our Allied Health Staff application packet. Please do not write see attached or see resume or CV on the application. All
More informationNew Jersey Physician Recredentialing Application (Please type or print)
New Jersey Physician Recredentialing Application (Please type or print) All sections must be completed fully or clearly marked as not applicable. No area should be left blank. SECTION 1 Personal Information
More informationLIBERTY DENTAL PLAN Provider Credentialing Application
(Complete one application per Provider) (* Required Fields) Credentialing Information: Owner: Associate: *PROVIDER NAME: DDS DMD Other (specify) *DATE OF BIRTH: / / Gender: Male Female Owning Dentist Name:
More informationName: Last First Middle. Mailing Address: Street City/State Zip Street Address: Street City/State Zip Telephone: ( ) Social Security Number:
School Nurse Application for Employment TANQUE VERDE UNIFIED SCHOOL DISTRICT, NO. 13 11150 E. Tanque Verde Road Tucson, AZ 85749 520-749-5751 / fax 520-749-5400 All positions require an Arizona Registered
More informationINSURANCE AGENT AGREEMENT
INSURANCE AGENT AGREEMENT THIS INSURANCE AGENT AGREEMENT is made, 200_ by and between Athens Area Health Plan Select, Inc. ( AAHPS or the Plan ), and ( Agent ). RECITALS: WHEREAS, AAHPS is licensed to
More informationBUSINESS ASSOCIATE AGREEMENT
BUSINESS ASSOCIATE AGREEMENT THIS BUSINESS ASSOCIATE AGREEMENT ( Agreement ) by and between OUR LADY OF LOURDES HEALTH CARE SERVICES, INC., hereinafter referred to as Covered Entity, and hereinafter referred
More informationE-RATE CONSULTING AGREEMENT
E-RATE CONSULTING AGREEMENT This E-Rate Consulting Agreement is made and entered into on this _6th_ day of August 2012 between the Harrisburg School District (the District ) and Julie Tritt-Schell (the
More informationAgreement for Services
Agreement for Services This Agreement is entered into as of the day of, 20, between Inc. ( the Company ) and ( the Contractor ). The purposes of this agreement are to define the rights and obligations
More informationFORM OF HIPAA BUSINESS ASSOCIATE AGREEMENT
FORM OF HIPAA BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement ( Agreement ) is made and entered into to be effective as of, 20 (the Effective Date ), by and between ( Covered Entity ) and
More informationAGREEMENT. Solicitor Without Per Diem Compensation
Solicitor Without Per Diem Compensation AGREEMENT Products underwritten by: American General Life Insurance Company Houston, Texas The United States Life Insurance Company in the City of New York New York,
More informationHOUSTON LAWYER REFERRAL SERVICE, INC. APPLICATION FOR MEMBERSHIP
HOUSTON LAWYER REFERRAL SERVICE, INC. APPLICATION FOR MEMBERSHIP The Houston Lawyer Referral Service, Inc. (HLRS) is a non-profit corporation sponsored by the Houston Bar Association, Houston Young Lawyers
More informationBROKER AND CARRIER AGREEMENT
P.O. Box 889 394 NE Hemlock Redmond, OR 97756 BROKER AND CARRIER AGREEMENT All loads tendered by Central Oregon Truck Company ("Broker") and accepted for transportation by third party carriers ("Carrier")
More informationPREPARED MANAGERS, LLC LIMITED AGENCY AGREEMENT. THIS INDEPENDENT AGENCY AGREEMENT, (this Agreement ) is made and entered into between
PREPARED MANAGERS, LLC LIMITED AGENCY AGREEMENT THIS INDEPENDENT AGENCY AGREEMENT, (this Agreement ) is made and entered into between PREPARED MANAGERS, LLC (the Company ) and (the Agent ). Prepared Managers,
More informationINDEPENDENT CONTRACTOR AGREEMENT (ICA)
INDEPENDENT CONTRACTOR AGREEMENT (ICA) (This agreement is not a construction contract within the meaning of Civil Code section 2783, and is not an agreement for the provision of construction services within
More informationApplication for Employment
Application for Employment GENERAL INFORMATION (Please Print) Name: Telephone No.: LAST FIRST MIDDLE Email Address: Present Address: Position Desired: STREET CITY STATE ZIP Pay Desired: If hired, can you
More informationINVESTMENT ADVISER REPRESENTATIVE AGREEMENT
INVESTMENT ADVISER REPRESENTATIVE AGREEMENT This investment adviser representative agreement ( Agreement ), made as of, 20, is between Partners for Prosperity, Inc., a Nevada corporation, with the principal
More informationDEPARTMENT OF HEALTH. APPLICATION FOR LIMITED LICENSURE and Instructions
DEPARTMENT OF HEALTH BOARD OF CLINICAL SOCIAL WORK, MARRIAGE AND FAMILY THERAPY AND MENTAL HEALTH COUNSELING APPLICATION FOR LIMITED LICENSURE and Instructions APPLICATION FOR LIMITED LICENSURE INSTRUCTIONS
More informationSERVICE AGREEMENT FOR FULL REIMBURSEMENT MANAGEMENT
SERVICE AGREEMENT FOR FULL REIMBURSEMENT MANAGEMENT This Service Agreement is entered into by and between the New Hampshire Alcohol and Other Drug Service Providers Association, a New Hampshire non-profit
More informationHow To Use A Health Care Program At Upmc
UPMC PRACTICE SOLUTIONS PARTICIPATION AGREEMENT This UPMC Practice Solutions Participation Agreement sets forth the terms and conditions pursuant to which (the Practice ), and the physician(s) listed on
More informationBUSINESS ASSOCIATE AGREEMENT
BUSINESS ASSOCIATE AGREEMENT THIS BUSINESS ASSOCIATE AGREEMENT is made and entered into as of the day of, 2013 ( Effective Date ), by and between [Physician Practice] on behalf of itself and each of its
More informationHow To Write A Contract Between College And Independent Contractor
Independent Contractor Agreement (Long Form) This Agreement is made between Babson College ("College"), a Massachusetts non-profit corporation with a principal place of business at 231 Forest Street, Babson
More informationFLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY
FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY APPLICATION FOR TEACHING PERMIT Chapter 466.002, Florida Statutes Rule 64B5-7.005, Florida Administrative Code Applications will be accepted only if completed
More informationGENERAL AGENT AGREEMENT
Complete Wellness Solutions, Inc. 6338 Constitution Drive Fort Wayne, Indiana 46804 GENERAL AGENT AGREEMENT This Agreement is made by and between Complete Wellness Solutions, Inc. (the Company ) and (the
More informationA. TERM OF AGREEMENT.
PRODUCER AGREEMENT This Producer Agreement (this Agreement ) is made and entered into between Coastal Insurance Underwriters, Inc. ( Coastal ) and, (the Producer ). A. TERM OF AGREEMENT. This Agreement
More informationAllied Healthcare Professional (AHP) Professional Liability Application
Allied Healthcare Professional (AHP) Professional Liability Application Coverys RRG, Inc. Agency Name NOTICE: This policy is issued by your risk retention group. Your risk retention group may not be subject
More informationREQUIREMENTS FOR LICENSURE:
Email: st-medicine@pa.gov INITIAL APPLICATION FOR A NURSE-MIDWIFE LICENSE 1. This license class does not include prescriptive authority. If you wish to hold a certificate for prescriptive authority, you
More informationINSURANCE AGENCY AGREEMENT
INSURANCE AGENCY AGREEMENT BritAmerica Management Group, Inc., hereinafter referred to as the Company, hereby appoints: Agent Agency Address City State Zip Tax ID hereinafter referred to as the Agent.
More informationNASI Per Diem Malpractice
Dear Nurse Anesthetist, We appreciate your interest in NASI s Per Diem Malpractice Insurance. This service is for those providers who need a supplemental policy for working an assignment outside of their
More informationMARYLAND DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT SMALL PROCUREMENT CONTRACT (FOR CONTRACTS OF $25,000 OR LESS) [Insert Contract Name and No.
MARYLAND DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT SMALL PROCUREMENT CONTRACT (FOR CONTRACTS OF $25,000 OR LESS) [Insert Contract Name and No.] THIS CONTRACT (the Contract ) is made as of the day
More informationCONSULTING AGREEMENT
CONSULTING AGREEMENT Agreement No. 2000398 Agreement dated 3/28/2000 by and between UserEdge Technical Personnel. ("USEREDGE") and CONSULTANT S CO., Tax ID No.99-9999999, including individually and collectively,
More informationDepartment of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing
MED THE STATE of ALASKA Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing State Medical Board PO Box 110806, Juneau, AK 99811-0806
More informationNevada Mutual Insurance Company
Nevada Mutual Insurance Company Professional Liability Coverage Ancillary Provider Application With your completed application, you must submit the following information: 1. Current declarations page.
More informationBUSINESS ASSOCIATE AGREEMENT FOR ATTORNEYS
BUSINESS ASSOCIATE AGREEMENT FOR ATTORNEYS This Business Associate Agreement (this Agreement ), is made as of the day of, 20 (the Effective Date ), by and between ( Business Associate ) and ( Covered Entity
More informationMaster Software Purchase Agreement
Master Software Purchase Agreement This Master Software Purchase Agreement ( Agreement ) is entered into as of Wednesday, March 12, 2014 (the Effective Date ) by and between with principal offices at (
More informationRESIDENT PHYSICIAN CONTRACT
RESIDENT PHYSICIAN CONTRACT THIS RESIDENT PHYSICIAN CONTRACT (the Agreement ) is made by and between «First» «Middle» «Last» ( RESIDENT ), of «Address», «City», «State_» «Zip» and Indiana University Health
More informationRULES OF THE ORANGE COUNTY BAR ASSOCIATION LAWYER REFERRAL & INFORMATION SERVICE. Purpose Section 1
RULES OF THE ORANGE COUNTY BAR ASSOCIATION LAWYER REFERRAL & INFORMATION SERVICE Purpose Section 1 The Lawyer Referral & Information Service Committee Section 2 Duties of the Lawyer Referral & Information
More informationAIT APPLICATION PACKAGE FOR REGISTRATION AS A PSYCHOLOGIST OR PSYCHOLOGICAL ASSOCIATE Version 2010-1
THE PSYCHOLOGICAL ASSOCIATION OF MANITOBA 162-2025 Corydon Ave., Box # 253, Winnipeg, Manitoba R3P 0N5 Phone: (204) 487-0784 Fax: (204) 489-8688 Email: pam@mts.net Website: www.cpmb.ca AIT APPLICATION
More informationMEDICAL LIEN CONTRACT. Date Patient Name Patient Date of Birth Date of Loss
MEDICAL LIEN CONTRACT Date Patient Name Patient Date of Birth Date of Loss Payment to Provider: I, ( Patient ), hereby authorize and direct you ( Attorney ), to pay directly to ( Provider ) AND/OR TO ANY
More informationHMSA BEHAVIORAL HEALTH FACILITY/PROGRAM CREDENTIALING DOCUMENT CHECKLIST
HMSA BEHAVIORAL HEALTH FACILITY/PROGRAM CREDENTIALING DOCUMENT CHECKLIST Enclosed you will find: A. HMSA Facility/Program Application form Please complete the application and include the requested documentation.
More informationCRNA INITIAL CREDENTIALING APPLICATION
CRNA INITIAL CREDENTIALING APPLICATION Revised 04/26 GENERAL INSTRUCTIONS Jackson CVO must credential all providers prior to placement into any practice location. All information requested in this application
More informationCONSULTING SERVICES and CONTRACT LABOR AGREEMENT
CONSULTING SERVICES and CONTRACT LABOR AGREEMENT This Consulting Services and Contract Labor Agreement ( Agreement ) is made and entered into as of the day of, 20 (the Effective Date ) by and between Volkswagen
More informationCAP CONSULTING SERVICES AGREEMENT
CAP CONSULTING SERVICES AGREEMENT This Agreement is made on this day of, by and between the College of American Pathologists, a not-for-profit Illinois corporation with offices at 325 Waukegan Road, Northfield,
More informationAgreement for Professional Emergency Services. professional emergency and related services provided at (hospital name) Hospital be
Agreement for Professional Emergency Services This Agreement, made and effective on (effective date) by and between (name of hospital) Hospital, Inc., located at (address of hospital), (city, state and
More informationAllied Health Professional Liability Insurance Application Form
Allied Health Professional Liability Insurance Application Form THIS APPLICATION IS FOR THE FOLLOWING PROFESSIONALS Physician s Assistant Perfusionist Certified Nurse Practitioner Surgeon s Assistant Optometrist
More informationPATIENT TRANSFER AGREEMENT
Appendix 2 SAMPLE PATIENT TRANSFER AGREEMENT THIS AGREEMENT is made effective as of by and between ( Children s Hospital) a nonprofit corporation, and ( Hospital ), a corporation. WHEREAS, operates a tertiary
More informationWeb Site Development Agreement
Web Site Development Agreement 1. Parties; Effective Date. This Web Site Development Agreement ( Agreement ) is between Plug-N-Run, its affiliates, (including but not limited to USA Financial, USA Financial
More informationTERMS OF BUSINESS AGREEMENT
TERMS OF BUSINESS AGREEMENT 2525 E Camelback Rd, Suite 800 As used in this Agreement, The Keating Group, Inc. (tkg) shall refer to any business unit or entity that may be affiliated through common ownership
More informationINDEPENDENT CONTRACTOR AGREEMENT FOR THE TRANSCRIPTION OF WESTMONT PLANNING AND ZONING COMMISSION MEETING MINUTES
INDEPENDENT CONTRACTOR AGREEMENT FOR THE TRANSCRIPTION OF WESTMONT PLANNING AND ZONING COMMISSION MEETING MINUTES THIS INDEPENDENT CONTRACTOR AGREEMENT ( Agreement ) is dated this day of February, 2014
More information