Provider Application

Personal Information

Full Name

Date of Birth

Gender

Male

Female

Other

Phone Number

Email Address

Home Address

City

State

ZIP Code

Emergency Contact Name & Relationship

Emergency Contact Phone

Professional Information

Position Applying For

Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Certified Nursing Assistant (CNA/HHA)

Physical Therapist

Occupational Therapist

Medical Social Worker

Other (Specify):

Professional License Number

State Issued

License Expiration Date

NPI Number (if applicable)

Are you authorized to work in the U.S.?

Yes

No

CPR Certification Valid Through

Experience

Years of Experience in Home Health

Previous/Current Employer

Role/Position

Supervisor's Name & Contact

Reason for Leaving

Can we contact your current employer?

Yes

No

Availability

Type of Employment Desired

Full-Time

Part-Time

Per Diem

Days Available

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Preferred Shift

Day

Evening

Overnight

Are you willing to travel between patient homes?

Yes

No

Compliance Documents

(Upload or submit copies as applicable)

Current Resume

Professional License(s)

CPR/BLS Certification

Driver's License/State ID

Social Security Card/Work Authorization

Immunization Record (including TB, Hepatitis B)

Background Check / Level 2 Fingerprint Clearance

Professional Liability Insurance (if applicable)

Upload Documents (if available now) You can upload multiple files. Max size: 10MB per file.

References

Reference 1 Name / Title / Contact

Reference 2 Name / Title / Contact

Statement of Understanding

Submit Application:

Upload all required documents or Email to: applications@healingbalmhealth.com

Healing Balm Home Healthcare Agency Provider Application Form