Embedded Files
Congratulations! If you've moved on to this page, you have submitted all documentation necessary to the application and interviewing process and are on your way to accepting your first independent contracting referral.
Once you have interviewed and are offered a referral to provide services that you would like to accept, the following documents will be needed to complete your file with our HR department and ensure that your first check will arrive on time.
- W-9 Form (see below for form)
- Exhibit A- Insurance Sign-Off (see below for form)
- Exhibit B- HIPAA Business Associate Agreement (see below for form)
- Act 24 Form/Arrest or Conviction Form (see below for form)
- Act 168 History Form (see below for form)
- Act 168 Form (see below for form)
- Copy of Professional Liability Insurance (COI - declaration page only)
- Please call or email the office if you need further information on obtaining insurance. Insurance is not needed to receive referral opportunities, but must be in place prior to starting with your first assignment.
- Copy of Driver's License and Social Security Card
These documents are available to you as ‘View Only’. In order for you to use these forms, you will need to save them to your computer first.
W9 Form.pdfInsurance Sign-Off Revised 102019.docxExhibit A- Insurance Sign-Off
HIPAA Business Associate Agreement Revised 102019.docxExhibit B- HIPAA Business Associate Agreement
Act 24 Form - Arrest or Conviction.pdfAct 24 Form/Arrest or Conviction Form
Act 168 History Form.docxAct 168 History Form
Act 168.pdfAct 168 Form
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