Credentialing Info

Signal Health Group

Credentialing Demographic Form

Type of Facility:

MedicalNon-MedicalBoth

Owner Information:

Name:

Title:

Date of Birth:

/ /

SSN:

- -

Gender:

MF

Driver’s Lic / ID Card Number:

State:

Alien Registration Card Number (if applicable):

Home Address:

-

Cell Phone:

- -

Fax:

- -

Other Names (previous names used):

Organization Information:

Proposed Organization Legal Name:

Control:

Tax ID:

-

NPI:

Mailing Address:

-

Property Address:

-

Phone:

- -

Fax:

- -

County:

Number of Locations/Satellite offices:

Business Office Hours: (Only days applicable)

Monday:

: ampm : ampm

Tuesday:

: ampm : ampm

Wednesday:

: ampm : ampm

Thursday:

: ampm : ampm

Friday:

: ampm : ampm

Saturday:

: ampm : ampm

Sunday:

: ampm : ampm

STAFFING:

Name of Administrator:

Hire Date:

/ /

Name of Director of Nursing:

Hire Date:

/ /

Total Number of Home Care Aides:

Electronic Funds Transfer (EFT) information:

Bank Name:

Contact Name:

Bank Address:

-

Bank Phone:

- -

Fax:

- -

Property Information:

OwnRent/LeaseOther

Property Owner information if Rent/Lease:

Name:

Address:

-

Phone:

- -

Registered Agent:

Name:

Physical Address:

-

Mailing Address:

-

Phone:

- -

Fax:

- -

Medical Director Information:

Name:

Mailing Address:

-

Phone:

- -

Fax:

- -

NPI:

Medicare #:

Medicaid #:

Include these items for Licensing Application:

State Licensing Application FeeVoided CheckCopy of Lease/DeedArticles of OrganizationCertificate of Liability Insurance page

Copies of: (for all employees and owner)

ResumeLicensesCertificationsBackground Check (transmittal app)Criminal Record Clearance
Partnership Agreement (if applicable)EIN acceptance letter from IRS (form SS-4)Signed W-9 formList of Counties serving