CBHC Employee Application

CBHC New Employee Application

Please complete all questions. Enter NA if NOT applicable.
Personal Information
Full Name

First NameMiddle InitialLast Name
Former / Other Name (if applicable)
Position you are applying for:
Date you are available to start

MonthDayYear
Date
Email Address
example@example.com
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Last 4 digits of SSN
Home address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Previous Addresses for last 5 years. If none, skip ahead.

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Previous Address 2

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Previous Address 3

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Previous Address 4

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Previous Address 5

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Gender
Date of Birth

MonthDayYear
Date
Marital Status
City / State of Birth
Country of Birth
Foreign Language Fluency
Other
Other language fluency
Are you an active member of the Military, Reserves, or National Guard?
Educational Information
High School
High School Location
High School Graduation Date

MonthDayYear
Date
Undergraduate School
Undergraduate School Location
Undergraduate Area of Study / Degree
Undergraduate Graduation Date

MonthDayYear
Date
Graduate School
Graduate School Location
Graduate Area of Study / Degree
Graduation Date

MonthDayYear
Date
Post Graduate School
Post Graduate School Location
Post Graduate Area of Study / Degree
Graduation Date

MonthDayYear
Date
Employment Information
Current Employer / Company Name
Your Title
From date

MonthDayYear
Date
To date

MonthDayYear
Date
Previous Employer 1 / Company Name
Your Title
From date

MonthDayYear
Date
To date

MonthDayYear
Date
May we contact this Employer?
Previous Employer 2 / Company Name
Your Title
From date

MonthDayYear
Date
To date

MonthDayYear
Date
May we contact this Employer?
Previous Employer 3 / Company Name
Your Title
From date

MonthDayYear
Date
To date

MonthDayYear
Date
May we contact this Employer?
Has there been any gap over 6 months within Employment, Education or Training? If yes, please explain.
Credentialling Information
Existing NPI (if applicable)
Existing Medicaid ID (if applicable)
Medicare ID
Insurance Companies with whom you are currently enrolled
References
Professional Reference 1 (Name & Title)
Company Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Nature of Work
Professional Reference 2 (Name & Title)
Company Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Nature of Work
Emergency Contact
Emergency Contact (Name)

First NameLast Name
Relationship
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Licensed Professionals
License Type
License Number
Issuing Board
License Expiration Date

MonthDayYear
Date
DEA License Number
CAQH
Have you ever been indicted or plead “guilty” or “no contest” to, or been convicted of, a crime? (Answering yes will not bar you from employment)
Has your license ever been revoked or suspended or are you involved in any proceeding that could affect it?
Have you had any professional liability actions against you in the last 10 years?
Have you been sanctioned by the Medicare program or any state Medicaid program in the last 10 years?
Signature
Digital Signature
Date

MonthDayYear
Date
Previous Employers
Should be Empty:

CBHC New Employee Application

Personal Information

Educational Information

Employment Information

Credentialling Information

References

Emergency Contact

Licensed Professionals

Signature