Therapist's Information Below you will need to upload a copy of your Bachelor’s Degree or Master’s Degree Diploma and a signed and dated copy of your accumulated hours!First Name* Last Name* Your Email* Your Phone*Your Date of Birth* Your Social Security Number* Your Gender* Male Female Clinic InformationWhat is the name of the clinic you are/will be working for?* What is the day you started working/will start at this clinic?*(First date treating patients) MM slash DD slash YYYY Criminal Conviction/Termination Disclosures The following questions are required by Forward Health/Medicaid to complete the enrollment process. You are the "applicant".Has the applicant ever been convicted of a criminal offense related to their involvement in any Federal health care program?* Yes No Has any person or entity having an ownership or control interest in the applicant ever been convicted of a criminal offense related to that person’s or entity’s involvement in any Federal health care program?* Yes No Has any agent of the applicant ever been convicted of a criminal offense related to that person's involvement in any Federal health care program?* Yes No Has any managing employee of the applicant ever been convicted of a criminal offense related to that person's involvement in any Federal health care program?* Yes No Has the applicant or any person or entity with a 5 percent or greater direct or indirect ownership interest in the applicant been convicted of a criminal offense related to that person's involvement with the Medicare, Medicaid, or title XXI program in the last 10 years?* Yes No Has the applicant been terminated on or after January 1, 2011, under title XVIII of the Social Security Act (Medicare) or under the Medicaid program or CHIP of any other State?* Yes No Upload a copy of your 1.) Bachelor’s Degree or Master’s Degree Diploma AND 2.) a signed and dated copy of your accumulated hours.* Drop files here or Select files Max. file size: 256 MB. Δ
