Toledo Ark - New Hire Digital Forms

All information must be filled out completely! Required fields are marked with *. This form will generate a PDF and send it directly to HR upon submission.

Application & Credentialing Form

NAME:*

DOB:*

GENDER:*

SSN:*

NPI#:

Medicare TIN#:

Medicaid#:

Credentials:

CAQH Provider #:

Attestation must be current (if applicable):

Full Home Address:*

Mailing Address (if different):

Phone #:*

Email:*

City where born:

State of Birth:

Country of Birth (if outside of US):

Location/Site:

Start Date:*

Best Time to Contact You:

Best Way to Contact Phone, email, etc...:

Please list all Certification and License #'s with Effective Dates and State Association:

List all College's Attended with EXACT DATES attended and completion date

College/University 1:

Start Date:

Completion Date:

Degree/Certificate:

College/University 2:

Start Date:

Completion Date:

Degree/Certificate:

College/University 3:

Start Date:

Completion Date:

Degree/Certificate:

List 2 Professional References with Contact Information. Address and Phone #

Reference 1 Name:

Address:

Phone #:

Email:

Reference 2 Name:

Address:

Phone #:

Email:

Work History for the past 5 years. Please list EXACT DATES worked with each Employer

Employer 1:

Position/Title:

Start Date:

End Date:

Reason for Leaving:

Employer 2:

Position/Title:

Start Date:

End Date:

Reason for Leaving:

Employer 3:

Position/Title:

Start Date:

End Date:

Reason for Leaving:

Please answer the following questions.

Have any of your board certifications ever been suspended, revoked or voluntarily surrendered?

Have your privileges at any hospital, facility, HMO or health plan been voluntarily or involuntarily surrendered, denied, suspended, revoked, restricted, limited, or placed on probation?

Have you ever been placed on probation or asked to resign from an internship, or other training program?

Has your malpractice insurance ever been cancelled, suspended, restricted, limited, special rated, or not renewed?

Has information pertaining to you ever been reported to the National Practitioner Data Bank?

STAFF EMERGENCY CONTACT

Name:*

Relationship:*

Address:*

City, State, Zip:*

Phone #:*

Emergency Contact Information

Primary Contact:*

Relationship:*

Phone:*

Form W-9 (Request for Taxpayer Identification Number and Certification)

1 Name of entity/individual:*

2 Business name/disregarded entity name:

3a Federal tax classification:*

LLC tax classification:

3b Foreign partners/owners/beneficiaries: Yes

4 Exemptions:

5 Address:*

6 City, state, and ZIP code:*

7 List account number(s):

TIN:*

Part II Certification
Under penalties of perjury, I certify that the information provided is true and correct.

Signature of U.S. person:*

Date:*

Form I-9 (Employment Eligibility Verification)

Section 1. Employee Information and Attestation

Last Name (Family Name):*

First Name (Given Name):*

Middle Initial (if any):

Other Last Names Used (if any):

Address (Street Number and Name):*

City or Town:*

State:*

ZIP Code:*

Date of Birth (mm/dd/yyyy):*

U.S. Social Security Number:*

Employee's Email Address:*

Employee's Telephone Number:*

Citizenship/Immigration Status:*

USCIS A-Number/I-94/Passport Info:

Signature of Employee:*

Today's Date (mm/dd/yyyy):*

Section 2. Employer Review and Verification

This section will be completed by HR after submission.

Confidentiality and Privacy Statement

As a contract employee of Toledo Ark, you may have access to confidential and sensitive information regarding our clients, employees, or organizational operations. This information may include protected health information (PHI) as defined under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as well as other personally identifiable information protected under the Privacy Act of 1974.

By signing this statement, you acknowledge and agree to the following:

Staff Name:*

Staff Signature:*

Date:*

Acknowledgement and Understanding of Policy & Procedures

As a contract employee of Toledo Ark, I acknowledge and agree to policies, procedures, and important matters included in the agency Policy & Procedures, which I have received on the date below:

Date Received - Agency Policy & Procedures:*

Additionally, as a contract employee of Toledo Ark, I acknowledge and agree to policies, procedures, and important matters included in the Staff Handbook, which I have received on the date below:

Date Received - Staff Handbook:*

Staff Name:*

Staff Signature:*

Date:*

Pre-Employment Criminal Conviction Statement

Applicant Information

Full Name:*

Position Applied For:*

Date of Birth:*

Address:*

Phone:*

Email:*

Have you ever been convicted of, pleaded guilty to, or been granted intervention in lieu of conviction for any offense listed above?

Signature:*

Date:*

Printed Name:*

Telephone Reference Form

Applicant Name:*

Date of Check:*

Reference 1

Name:

Years Known:

Relationship:

Reference Organization:

Phone #:

Best time to call:

Reference 2

Name:

Years Known:

Relationship:

Reference Organization:

Phone #:

Best time to call:

Reference 3

Name:

Years Known:

Relationship:

Reference Organization:

Phone #:

Best time to call:

By submitting, you agree that all information is true and complete. The forms will be sent to HR automatically.