Subcontractor Onboarding Application

Subcontractor Onboarding Application
Thank you for your interest in contracting with THHN Consulting LLC. This onboarding form collects your professional credentials, availability, compliance documents, and agreement signatures needed to place you with our home health and home care agency partners. Please have the following documents ready before you begin: Professional License, Proof of Liability Insurance, CPR Certification, Resume/CV, and a completed W-9. Estimated completion time: 20–30 minutes.
Required to Continue

Personal Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth:

MonthDayYear
Date
Are you authorized to work in the United States?
Reliable Transportation?
Valid Driver's License?

Professional Credentials & Licensure
Primary Discipline:
Additional Disciplines:
NPI Number (If Applicable)
Upload Professional License:

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Business & Tax Info
Upload Completed W9 form. If you need a copy to fill out please click on the link below:

https://www.irs.gov/pub/irs-pdf/fw9.pdf
Upload Completed W9 Form:

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Do you have Professional Liability Insurance?
If Yes, Please Upload Professional Liability Insurance here:

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Please Upload CPR Card:

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Availability
Please Enter Cities or Counties you are available to cover:
Maximum Travel radius:
Weekly Caseload Availability:
Earliest Start Date:

MonthDayYear
Date

INDEPENDENT CONTRACTOR AGREEMENT
THHN Consulting LLC

This Independent Contractor Agreement ("Agreement") is entered into between THHN Consulting LLC, a Florida limited liability company ("Company"), and the individual identified in this onboarding application ("Contractor").

1. INDEPENDENT CONTRACTOR RELATIONSHIP
Contractor is engaged as an independent contractor and not as an employee. Contractor is solely responsible for all taxes.

2. SERVICES
Contractor agrees to provide therapy services to patients referred by Company's agency partners within the agreed service area.

3. COMPENSATION
Company will pay Contractor at the agreed rate. Payment within 14 days of verified documentation.

4. DOCUMENTATION AND RECORDS
Contractor shall complete all required clinical documentation per standards.

5. TERM AND TERMINATION
Either party may terminate upon 14 days' written notice. Immediate termination for cause.

6. CONFIDENTIALITY AND HIPAA
Contractor agrees to comply with HIPAA. This obligation survives termination.

7. NON-SOLICITATION
12-month non-solicitation period following termination.

8. PROFESSIONAL STANDARDS
Contractor agrees to maintain all licenses, insurance ($1M/$3M minimum), and comply with all laws.

9. INDEMNIFICATION
Contractor shall indemnify Company from claims arising from Contractor's services.

10. INDEPENDENT VERIFICATION
Contractor authorizes Company to verify licensure, NPI, exclusion status, insurance, and background.

11. NO GUARANTEE
No minimum assignments guaranteed.

12. GOVERNING LAW
Governed by Florida law. Binding arbitration in Palm Beach County.

13. ENTIRE AGREEMENT
This constitutes the entire agreement.

14. SEVERABILITY
If any provision is unenforceable, the remaining provisions remain in effect.

Contractor acknowledges having read, understood, and agreed to all terms.
I have read the entire Agreement and agree to be bound by its terms.
Full Name:

First NameLast Name
Signature
Date

MonthDayYear
Date

Payment Preferences & Emergency Contact
Preferred Payment Method
Emergency Contact Info:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Should be Empty:

Subcontractor Onboarding Application

Personal Information

Professional Credentials & Licensure

Business & Tax Info

Availability

HIPAA Compliance & Background Authorizations

Background Screening Consent

Certifications

Payment Preferences & Emergency Contact