Credentialing Demographic Form
Name:
Title:
Date of Birth:
SSN:
Gender:
Driver’s Lic / ID Card Number:
State:
Alien Registration Card Number (if applicable):
Home Address:
Cell Phone:
Fax:
Email:
Other Names (previous names used):
Proposed Organization Legal Name:
Control:
Tax ID:
NPI:
Mailing Address:
Property Address:
Phone:
County:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
Name of Administrator:
Hire Date:
Name of Director of Nursing:
Total Number of Home Care Aides:
Bank Name:
Contact Name:
Bank Address:
Bank Phone:
Property Owner information if Rent/Lease:
Address:
Physical Address:
Medicare #:
Medicaid #:
Copies of: (for all employees and owner)
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