Facility Enrollment Form
Facility Name:
*
Operating License Number:
*
Facility Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Facility Phone Number:
*
Please enter a valid phone number.
Facility Email Address:
*
example@example.com
Business entity:
*
Please type the name of your legal entity that the facility operates under.
Tax ID:
*
EIN
Mailing Address (if different from Facility's address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Point of contact:
*
First Name
Last Name
Phone Number for Point of Contact:
*
Please enter a valid phone number.
Email Address for Point of Contact:
*
example@example.com
What are your facility's staffing needs?
*
Licensed Caregiver
Certified Nursing Assistant (CNA)
Behavioral Health Technician (BHT)
Medication Technician
Article 9
Dementia/Memory Care
Other
Please provide a copy of your facility license.
*
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Please provide a copy of your current liability insurance.
*
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Please add any information you consider to be relevant for us. Kindly do not include and HIPAA protected information.
Agreement
*
I confirm the accuracy of all information submitted.
By submitting this Facility Enrollment Form, our facility acknowledges its intent to contract with Instant Care Aid™ and understands that a formal Staffing Agreement will be sent electronically for signature.
Signature:
*
Submit
Submit
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