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
PA / NP Application Personal Last Name First Name Middle Previous Name Nickname Social Security # NPI # Street Address Apt. # City State Zip Phone ( ) E-mail Cell ( ) E-mail 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 1. 2. 3. 4. 5. 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
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 ( ) E-mail 2. Name Title Years acquainted Facility Street Address City State Zip Phone ( ) E-mail 3. Name Title Years acquainted Facility Street Address City State Zip Phone ( ) E-mail 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
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
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
8. Contractor shall review and abide by the Provider Handbook that Finder will issue to Contractor and which is also located on www.unitedanesthesia.com, 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 $12,000.00 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 $12,000.00 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
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
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 1.855.671.1058 A corporate representative will work with me to resolve my concern. PA / NP Signature Date Print Name Page 8 of 8