Independent Contractor Information Form

Personal Information

First Name:

Middle:

Last:

Home Address (no P.O. Boxes):

Mailing Address:

Home Phone:

Cell Phone:

Work Phone:

Person to Notify in Case of Emergency

Primary Emergency Contact

First Name:

Last Name:

Relationship to you:

Mailing Address:

Home Phone:

Cell Phone:

Work Phone:

Job Specific Information

Certification:

CPMSM CPCS CPQH None

Willing to commit to long-term assignments? (more than two months):

Yes No

Which States are your preferred choices for assignments?:

How frequently must you go home when traveling? (indicate if no preference):

Other travel limitations:

Which type of assignments would you like? (check as many as applicable):

Data Entry File Audit Credentials Specialist Medical Staff Coordinator Supervisor or Manager

Director of MSS Director of Quality Any Position Other

If other, please indicate:

Which type of credentialing software are you familiar enough to work on without being trained?:

Check any of the following in which you have 10+ years of experience and the skills to perform for our clients:

Assessments of the Medical Staff Office
Staffing Evaluations
By-Laws Development
Delineation of Privileges' Development
Database Review
Analysis and Training
MSO Training and Education

Do you have proof of a current TB test?:

Yes No

(If within the past 12 months from today's date, what was the date of the test?):

Note: A client may require a TB and drug test, criminal background check and/or proof of verification of vaccines prior to beginning an assignment.

I have read and understand – Please Check Box

HISG requires that Consultants, who use their personal automobile when servicing HISG clients, maintain current automobile insurance on their vehicle.

I acknowledge and understand – Please Check Box

I have current automobile insurance on my personal auto

Yes No

Email Address:

By submitting this information form, I affirm that the facts set forth in it are true and complete. I understand that HISG will verify my work history and if I am accepted as an independent consultant, any false statements, omissions, or other misrepresentations made by me on this information form may result in immediate termination of any contract(s) I am involved in.

I have read and understand – Please Check Box

Enter todays date: