Credential Submission Form
Please use this form for submission of your documentation & credentials. Answer the questions and enter each document in the corresponding container by either copy/paste or drag and drop. You may save the document in progress (you will receive an email with a link to continue). THANK YOU for your assistance and we are excited to consider you for our firm.
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Name
*
First Name
Last Name
MI
MI
Nickname
If you prefer to go by a nickname rather than your given name, enter it here.
Email
*
example@example.com
Mobile Phone
*
Please enter a valid phone number.
Home Number
If you have a different home number, please enter.
Fax Number
If you have a different fax number, please enter.
Address
*
Street Address
Street Address Line 2
City
State (Two Letter Postal Code)
Zip Code
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Verification
I expressly authorize Aptiva Therapy, LLC to contact educational and governmental institutions, references, and employers for additional information and/or verification of the authenticity of the credentials I submit, including, but not limited to, sending copies of credentials to the institution.
Authorization for Release
I expressly authorize Aptiva Therapy, LLC to release information about me; including my contact information, educational, licenses, medical & other personnel records where these are required by the contracting home health agency for whom I will be performing services to satisfy requirements from regulatory or accrediting agencies. I agree to keep these credentials current and in good standing.
Certification
I certify that the information and the credentials that I have provided to Aptiva Therapy, LLC are true and accurate. I have read and agree to the release of my information as required by agencies contracting with Aptiva Therapy, LLC. This authorization shall remain in effect for the period of time for which I continue to provide services, and continue for a period of 1 year after the last date that I perform services for Aptiva Therapy, LLC and it’s contracting home health agencies.
Signature
*
Print Name Here
*
Date
*
-
Month
-
Day
Year
Date
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Highest Clinical Degree Obtained
Please Select
Doctorate
Masters
Bachelors
Date of Degree
-
Month
-
Day
Year
Date
Institution Obtained From
Copy of Degree Diploma if available
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Drop a photo or PDF of your degree here if available
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Languages
Arabic
Bengali
Chinese
French
German
Hindi
Japanese
Polish
Punjabi
Korean
Portuguese
Russian
Spanish
Tugalog
Other
Geography
Enter a detailed description of the area you cover, such as the boundaries by street to the North, West, South and East, or a general description i.e. From Oakbrook to Aurora below IL38 and above 75th Street
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References
Please enter two professional references.
Ref 1 Name
Enter the name of your reference
Email
example@example.com
Ref 1 Role
Enter his or her role
Ref 1 Phone Number
Enter His or Her Phone
Ref 2 Name
Enter the name of your reference
Email
example@example.com
Ref 2 Role
Enter his or her role
Ref 2 Phone Number
Enter His or Her Phone
Ref 3 Name
Ref 3 Email
example@example.com
Ref 3 Role
Ref 3 Phone Number
Please enter a valid phone number.
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Work History
Resume
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Upload a current resume or CV
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Copy of License(s)
Please copy and paste your clinical license below.
Add Illinois License
Clinical License IL
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Enter a copy of your clinical license here. If you are licensed in multiple states, enter your state of residence first and additional license below.
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Date License Effective
-
Month
-
Day
Year
Date
Date License Expires
-
Month
-
Day
Year
Date
License Number
Add Kansas License
Clinical License KS
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Enter a copy of your clinical license here. If you are licensed in multiple states, enter your state of residence first and additional license below.
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Date License Effective KS
-
Month
-
Day
Year
Date
Date License Expires KS
-
Month
-
Day
Year
Date
License Number KS
Add Missouri License
Clinical License MO
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Enter a copy of your clinical license here. If you are licensed in multiple states, enter your state of residence first and additional license below.
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Date License Effective MO
-
Month
-
Day
Year
Date
Date License Expires MO
-
Month
-
Day
Year
Date
License Number MO
Add Wisconsin License
Clinical License WI
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Enter a copy of your clinical license here. If you are licensed in multiple states, enter your state of residence first and additional license below.
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Date License Effective WI
-
Month
-
Day
Year
Date
Date License Expires WI
-
Month
-
Day
Year
Date
License Number WI
Add an Additional License
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Current Drivers License
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Upload an photo or scan of your driver's license
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DL issue date
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Month
-
Day
Year
Date
DL expiration date
-
Month
-
Day
Year
Date
DL State
Contract
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Please upload your signed contract here.
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Signed Contract Date
-
Month
-
Day
Year
Date
Form W9
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Copy the completed form W9 here
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W-9 Date
-
Month
-
Day
Year
Date
Background Check Authorization
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Enter the signed background check authorization here.
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Background Check Authorization Date
-
Month
-
Day
Year
Date
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HIPAA Confidentiality
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Copy the HIPAA confidentiality agreement here
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HIPAA Agreement Date
-
Month
-
Day
Year
Date
Physician's Statement of Good Health
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Copy the Physician's Statement of Good Health or similar healthcare worker authorization
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Physicians Statement of Good Health Effective Date
-
Month
-
Day
Year
Date
Physicians Statement Date
-
Month
-
Day
Year
Date
TB Skin Test
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Place your TB Skin Test letter or other proof here
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TB Test Date
-
Month
-
Day
Year
Date
COVID-19 Vaccine Certificate
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Choose a file
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Final Covid Vaccine Date
-
Month
-
Day
Year
Enter the Date of your Last Shot (Only Date if J&J)
Statement of Influenza Vaccination
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Enter the Vaccination Statement Here
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Flu Vaccine Date
-
Month
-
Day
Year
Date
Statement of Hepatitis B Vaccination
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Choose a file
Copy the Hepatitis Vaccination here
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Hep B Vaccine Date
-
Month
-
Day
Year
Date
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Job Acknowledgement
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Copy the Role Description here
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Contractor Guidebook Acknowledgment
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Choose a file
Sign and insert copy Page 21 of the Guidebook here
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Workers Compensation Opt Out Form
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If you are a sole proprietor or S Corp working under your social security number or an FEIN, complete Part A, using your name or entity name. If you have a partnership, complete Part B, and for an LLC, enter your FEIN and signatures under Part C.
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Workers Comp Opt Out Date
-
Month
-
Day
Year
Date
Photo
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Drag and drop files here
Choose a file
Photo suitable for ID Badge
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Performance Review
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If you have a recent Performance Review, please upload a copy here. This will remain fully confidential and is NOT released to any agency. We do however, have to be able to certify that you have received a performance review within the last 12 months for certain agency accreditation's.
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Thank YOU!
The 2018 changes to the Medicare Home Health Certificate of Participation effectively requires staffing firms to keep all records that would normally be attributed to an employee. Thank you for taking the time to complete the requisite credentials. Please let me know at (224) 216-3518 or Jeff.Mathis@AptivaTherapy.com if there are any questions. You may stage submissions by duplicate entries, with the most important and initial requirements being the contract, your professional licenses, your Drivers License, your Auto Insurance and your CPR card.
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