• Travel Assignment Application Form

    Please complete all required fields to complete your Traveler Profile. PLEASE NOTE: Profile completion typically takes 2–4 business days, depending on the turnaround time for references, skills checklists, and supporting documents.
  • Format: (000) 000-0000.
  • Work Authorization Status: Please note that only candidates who are U.S. Citizens or Green Card holders are eligible for this position at this time.*
  • To help us support your assignment and benefits planning, what is your health coverage preference during your assignment?
  • Start Date Availability*
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  • Reference Person 1

  • Format: (000) 000-0000.

  • Reference Person 2

  • Format: (000) 000-0000.

  • Compliance & Confidentiality Acknowledgment

  • During your assignment with Acquire Medstaff, you may have access to Protected Health Information (PHI) and other confidential information related to patients, clients, and healthcare facilities.

    You are required to maintain strict confidentiality and comply with all applicable HIPAA regulations and facility policies.

    Please confirm the following:

     

  • Do you acknowledge and agree to comply with HIPAA confidentiality, privacy, and security requirements during your assignment with Acquire Medstaff?*

  • By selecting “Yes,” you acknowledge that a separate Confidentiality and HIPAA Acknowledgment Agreement will be sent to your email for electronic signature. This document must be completed as soon as possible, as it is required for assignment eligibility.

  • Candidate Compliance Verification

  • Are you able to complete required employee health screenings, immunization verification, and compliance requirements if selected for placement?*
  • Please confirm your understanding of the following requirement: A copy of your Social Security card may be required as part of employment verification and facility onboarding compliance. The name on your Social Security card must match your submitted government-issued ID exactly.*

  • Authorization to Represent (ATR)

  • Some healthcare facilities and vendor management systems require a signed Authorization to Represent (ATR) authorization before a candidate can be submitted for consideration.

    By selecting “Yes” below, you acknowledge that you authorize Acquire Medstaff, LLC to represent you for the assignment discussed with our team. A separate ATR authorization form will be automatically sent to you via email for electronic signature and completion.

    Please note that submission to a facility cannot proceed until the ATR document has been completed, if required by the client or vendor.

  • Do you authorize Acquire Medstaff, LLC to represent you for this assignment?

  • Privacy & Communication Consent

  • You can unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy.

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