Pre-Employment Information Step 1 of 4 - Contact Information 25% Date MM slash DD slash YYYY Choose the date of contact with the clinician.Clinician's Name* First Last Clinical License*Please ChoosePT - Physical TherapistPTA - Physical Therapist AssistantOT - Occupational TherapistCOTA - Occupational Therapy AssistantSLP - Speech PathologistPhone Number*Email* Home Address* Street Address Apartment or Unit Number City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Documentation Software Experience* Kinnser / WellSky Home Care Home Base / Point Care Other Agreeable To Accept HCHB/Pointcare Patients* YES NO Agreeable To Be TRAINED on HCHB/Pointcare Patients* YES NO List Other Software Days Available to Work Select All Sunday Monday Tuesday Wednesday Thursday Friday Saturday Find ZIP Codes Inside User-Defined AreaCoverage Territory* Example: Specific Cities, General Areas or Hard BoundariesTypes of Physical Therapy visits to schedule Select All PT OASIS - Kinnser PT Assessments - Kinnser PT Visits - Kinnser PT OASIS - HCHB PT Assessments - HCHB PT Visits - HCHB Types of Occupational Therapy visits to schedule Select All OT Assessments - Kinnser OT Treatments - Kinnser OT Assessments - HCHB OT Treatments - HCHB Types of Speech Therapy visits to schedule Speech Pathologists perform Assessments and Treatments Types of Physical Therapist Assistant visits to schedule PTA's can only perform treatments Types of Occupational Therapy Assistant visits to schedule COTA's can only perform treatments Employment Status*Please ChooseEmployee - W2 (No Benefits)Employee - W2 (With Benefits)Independent Contractor - 1099Split Rate?* No Yes Eval RateProvide the per visit reimbursement discussed with the clinician.Visit Rate*Provide the per visit reimbursement discussed with the clinician.Projected PayrollProjected Payroll Special Notes
