Get Nfm-es-locum-contract-app-00 Locum Tenens And Contract Staffing Org App (11-14).pub

Filling out the NFM-ES-LOCUM-CONTRACT-APP-00 Locum Tenens and Contract Staffing Organization Application can seem daunting, but with this guide, you'll understand how to complete it online efficiently. This step-by-step instruction will help ensure that you provide all necessary information accurately.

Follow the steps to successfully complete the application.

1. Press the 'Get Form' button to access the form and open it in your preferred online editor.
2. Begin with section I, General Information. Fill in the name of your organization, mailing address, email, and phone number. Ensure all details are complete and accurate.
3. Select your organization's type by choosing from the options provided: Sole Proprietor, Corporation, Limited Liability Corporation, or Other.
4. If applicable, indicate if your organization operates under a different name by selecting Yes or No and providing that name if necessary.
5. Complete the section regarding the organization's operational history, including the year established and management experience.
6. Proceed to detail key personnel by indicating if your organization has a Medical Director, Credentialing contact, Claims Management contact, and Risk Management contact. Provide their contact information if applicable.
7. Enter the number of employees, both W-2 and Non W-2, categorized by full-time and part-time.
8. Answer the question regarding compliance with the Health Insurance Portability and Accountability Act (HIPAA) and provide the name of your privacy officer if applicable.
9. Prepare to attach necessary documents, including CVs for key personnel, claims management protocols, financial statements, and sample contracts.
10. Fill out section II, Professional Services, which includes anticipated and past revenue, along with any involvement in Patient Compensation Fund states.
11. Provide details in section III, Locum Tenens, noting the facility types where staffing services are provided and any required insurance coverage for staff.
12. In section IV, if your organization is a Contract Staffing Organization, list contracted agreements and details regarding locum tenens services.
13. Moving to section V, outline your organization's risk management procedures and ensure to note if you have any formal risk management programs.
14. Complete sections VI to IX as instructed, detailing liability coverages, loss history, and agree to the provided notices and agreements.
15. Finally, review all filled sections for accuracy. Save your changes, then decide whether to download, print, or share the form as needed.

Complete your application online today for efficiency and accuracy.