Get Nursing Referral Service Agency Form

Filling out the Nursing Referral Service Agency Form is a crucial step for agencies seeking licensure in Maryland. This guide provides clear and detailed instructions to assist you in completing the form effectively and accurately.

Follow the steps to complete the Nursing Referral Service Agency Form online.

1. Click the ‘Get Form’ button to retrieve the Nursing Referral Service Agency Form and open it in your selected editor.
2. Begin by providing your general information. This includes the name of your agency, address, and contact details. Ensure that all entries are accurate as this information is essential for communication.
3. Next, move to the fees section. Include the non-refundable application fee of $1,000. Ensure payment is detailed correctly, as starter checks are not acceptable.
4. Complete the ownership section. List all officers and directors, including their names and addresses, as required by the regulations.
5. In the background section, provide information pertaining to the required background checks and any relevant certifications for health professionals, adhering to the guidelines set forth.
6. Fill out the workers’ compensation section. If your agency does not have workers’ compensation insurance and has no employees, ensure you provide the necessary exemption documentation.
7. Complete the affidavit section, affirming that all information provided is accurate to the best of your knowledge.
8. If applicable, submit the addendum verification form, ensuring all required policies and procedures are documented, as outlined in the instructions.
9. Before finalizing, review your form for completeness. Add any required documentation to ensure your application is not returned due to missing information.
10. Once you have completed all sections and attached the necessary documents, save your changes, download a copy for your records, print the form, and submit it to the designated office.

Begin your application process now by filling out the Nursing Referral Service Agency Form online.