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Indiana Health Care Services (800) 260-6145
Franchise (800) 953-6183
info@signalhg.com

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Credentialing Info

Signal Health Group

Credentialing Demographic Form

Type of Facility:

Type of Facility:

Medical Non-Medical Both

First Name

Middle Name

Last Name

Title

Date Of Birth

SSN

Gender

Gender

Male Female

Driver’s Lic / ID Card Number

State

Alien Registration Card Number (if applicable):

Home Address

Steet

City

State

ZIP

Cell Phone

Fax

Email

Other Names (previous names used)

Organization Information

Proposed Organization Legal Name:

Control

Control 1

Control 2

Tax ID

NPI

Mailing Address

Steet Organization

City Organization

State Organization

ZIP Organization

Property Address

Steet Property

City Property

State Property

ZIP Property

Phone Organization

Fax Organization

County

Number of Locations/Satellite offices

Business Office Hours: (Only days applicable)

Monday

From (Monday)

To (Monday)

Tuesday

From (Tuesday)

To (Tuesday)

Wednesday

From (Wednesday)

To (Wednesday)

Thursday

From (Thursday)

To (Thursday)

Friday

From (Friday)

To (Friday)

Saturday

From (Saturday)

To (Saturday)

Sunday

From (Sunday)

To (Sunday)

STAFFING

Name of Administrator or Manager:

Hire Date

Name of Director of Nursing or Alternate Manager:

Hire Date 2

Total Number of Home Care Aides

Electronic Funds Transfer (EFT) information

Bank Name

Contact Name

Bank Address

Street Bank

City Bank

State Bank

Zip Bank

Bank Phone

Fax Bank

Property Information

Property Information

Own Rent/Lease Other

Property Owner information if Rent/Lease

Name (property if leased/rent)

Address

City

Address

State

Zip

Phone

Registered Agent

Name Agent

Physical Address

Street

City

State

Zip

Mailing Address

Street

City

State

Zip

Phone

FAx

Name

Street

City

State

Zip

Phone

FAx

NPI

Medicare #

Medicaid #

Include these items for Licensing Application:

Licensing

State Licensing Application Fee Voided Check Copy of Lease/Deed Articles of Organization Certificate of Liability Insurance page

Required Documents

Criminal Background Check

Business License

CLIA (if Appliiable)

Certificate of Incorporation

Board Certificate

Malpractice Certificate

Collaborative Agreement

Ownership Information (SSN)

Organizational Chart

Program Description

Background Check:

Copies of: (for all employees and owner)

Licensing

Resume Licenses Certifications Background Check (transmittal app) Criminal Record Clearance Partnership Agreement (if applicable) EIN acceptance letter from IRS (form SS-4) Signed W-9 form List of Counties serving

Upload Files

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Signal Corporate Office

3753 Howard Hughes Parkway #200 Las Vegas, NV 89169
Indiana Health Care Services (800) 260-6145
Nevada Care Services
(702) 843-0579
Franchise (800) 953-6183
info@signalhg.com

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