Get Individual Application Date: Applicant - Employee Resource ...

Filling out the INDIVIDUAL APPLICATION form is essential for providing necessary information to Employee Resource Systems, Inc. This guide offers a step-by-step approach to ensure you complete the application accurately and efficiently online.

Follow the steps to successfully complete your application.

1. Click the ‘Get Form’ button to obtain the form and open it in the appropriate editor.
2. Fill in the date at the top of the form. This is the date when you are completing the application.
3. Provide your full name in the 'Applicant Name' field.
4. Enter your email address in the 'Email Address' field to ensure you can receive further correspondence.
5. Fill in the 'Group Name' field as applicable to your application.
6. Input your Tax Identification Number (Tax ID#) in the designated section. This is important for processing your application.
7. Indicate the name of the entity to which checks should be payable in alignment with your Tax ID#. This could be your own name or a business name.
8. Complete the 'Billing Address' section, including the street address, city, state, and zip code.
9. Provide your primary clinical office location, including the full address, city, state, and zip code.
10. If applicable, provide a secondary address and the relevant telephone numbers for referrals and clients.
11. Fill in your license number(s), the state of issuance, and expiration date if you hold any licenses relevant to your practice.
12. Provide your National Provider Identifier (NPI#) if you have one.
13. Indicate which insurance panels you belong to by circling the appropriate options.
14. Answer the series of yes/no questions honestly. If you answer 'yes' to any question, attach a full explanation as required.
15. Specify your availability by checking the days of the week you are available and indicating your working hours.
16. Select your areas of specialization by checking the relevant boxes provided.
17. List any populations you feel uncomfortable working with in the designated space.
18. Review all entered information for accuracy before saving the form.
19. Finally, save your changes, and you may choose to download, print, or share the completed form as needed.

Start completing your documents online today for an efficient application process.