Your Basic Info
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Desired Staus
Are you a 1099 DOH Approved Provider?
Preferred Coverage Areas

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1. Resume

Resume Upload File

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2. SCR Clearance Form - click here for blank

SCR Upload File

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3. Physical Exam - click here for blank

Physical Exam Upload File

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4. Recommended Vaccinations - 


Click here to read, fill, & sign

5. NYS Licsense/ Certificate / Degree (this option is for SCs only)

License/Cert/Degree Upload File

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6. I9 Form - click here for blank

I9 Upload File

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7. Copy of Passport

Passport Upload File

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Submit Your Docs

For ​ALL Staff, please submit:

8. Copy of Driver's License/State ID

ID Upload File

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9. References - please include 3 references

Reference Upload File

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10. NPI # - if you do not have NPI#, please click here to register for one

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11. Continuing Education Certificates -     10 hrs needed per year. Click here for specific requirements

Certificates Upload File

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12. Training Certificates - sign up & take the 5 modules on Family Centered Practice here 

Certificates Upload File

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13. Sexual Harassment Prevention Training - click here for training link

Anti-Sexual Harassment Upload File

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14. COVID Vaccination Card - or Excelsior Pass
Screenshot

COVID Vaccination Upload File

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15. Proof of Malpractice Insurance - need $1 million per claim/$3 million aggregate. For company suggestion, click here. (If you are a SC, you do not need this)

Malpractice Upload File

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16. Direct Deposit Form - click
here for blank

Direct Deposit Upload File

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17. Acknowledgement of Provider Compliance (Part I) - (this is for therapists only)

Click here to read, fill, & sign

18. Acknowledgement of Provider Compliance (Part II) - (this is for therapists only)

Click here to read, fill, & sign

19. Confidentiality Agreement - 


Click here to read, fill, & sign

20. Drug/Alcohol Declaration - 


Click here to read, fill, & sign

For ​W2 Employees ONLY, please ALSO submit:

1. W4 Tax Form - click here for blank

W4 Upload File

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2. IT-2104 Form - click here for blank

IT-2104 Upload File

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3. Employee Contract - (Therapists - click here for
blank / SCs - click here for blank)

Employee Contract Upload File

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OR

For ​1099 Employees ONLY, please ALSO submit:

1. DOH Approval Letter - or to apply, click here

DOH Letter Upload File

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2. 1099 Tax Form - click here for blank

1099 Upload File

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3. Independent Contractor Contract - click here for blank

IC Contract Upload File

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