Credentialing Info Signal Health Group Credentialing Demographic Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Type of Facility: *MedicalNon-MedicalBothName *FirstMiddleLastSingle Line Text *Date / Time *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Single Line TextGenderMaleFemaleSingle Line TextSingle Line Text *Alien Registration Card Number (if applicable):Home Address *Address Line 1CityState AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNameFirstLastSingle Line Text *Single Line TextOrganization Information Control Control SelectProfitNon ProfitSelectSelectLimited Liability CorporationCorporationSole ProprietorS-CorporationPartnershipSingle Line TextSingle Line Text Mailing Address Mailing AddressSingle Line TextSingle Line TextSingle Line Text Property Address Property AddressSingle Line TextSingle Line TextSingle Line TextSingle Line TextSingle Line TextFaxNumber of Locations/Satellite offices Business Office Hours: (Only days applicable) Monday Monday Tuesday TuesdayMonday (copy) Wednesday TuesdayMonday (copy) Thursday ThursdayMonday (copy) Friday ThursdayMonday (copy) Saturday ThursdayMonday (copy) Sunday ThursdayMonday (copy)STAFFINGHire DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Single Line TextHire Date 2MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Text Upload Text Single Line TextElectronic Funds Transfer (EFT) informationElectronic Funds Transfer (EFT) Bank Address Bank AddressSingle Line TextSingle Line TextSingle Line TextBank AddressBank Address (copy)Property InformationOwnRent/LeaseOtherProperty Owner information if Rent/Lease Address AddressSingle Line TextSingle Line TextSingle Line TextSingle Line TextRegistered AgentPhysical AddressSingle Line TextSingle Line Text (copy)Single Line Text (copy) (copy)Mailing AddressSingle Line TextSingle Line Text (copy)Single Line Text (copy) (copy)Single Line TextSingle Line TextSingle Line TextPhoneSingle Line TextNPISingle Line TextSingle Line Text (copy)Include these items for Licensing Application:State Licensing Application FeeVoided CheckCopy of Lease/DeedArticles of OrganizationCertificate of Liability Insurance pageSingle Line TextSingle Line TextSingle Line TextSingle Line TextSingle Line TextSingle Line TextSingle Line TextSingle Line TextSingle Line TextSingle Line TextParagraph TextCopies of: (for all employees and owner)ResumeLicensesCertificationsBackground Check (transmittal app)Criminal Record ClearancePartnership Agreement (if applicable)EIN acceptance letter from IRS (form SS-4)Signed W-9 formList of Counties servingFile UploadSubmit Background Check: Click for your background check where to go for NPI ?
