Become A Click Clinician

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Let's Get Your Application Started!

First Name *

Last Name *

Email *

Preferred Patient Zip Codes *

Visits Per Week *

1-3

3-5

5-10

Over 10

Please put the rate per visit you would like. PT,OT, ST, put evaluation rate, RA/DC and regular visit. Assistants just visit rateRate Per Visit *

Therapy License Expiration Date *

CPR Expiration date *

TB Expiration Date

Driver's License Expiration Date *

Auto Insurance Expiration Date *

Professional License Copy *

Driver's License Photo *

Legal First Name *

Legal Last Name *

City *

State *

Postal code *

SSN/ITIN (this information is required in order to pay you) *

Address *

Phone *

I certify that the above information is correct

TB Signs and Symptoms Signature *

Clear

Business Associate Agreement *

Clear

Read PDGM *

Clear

Read Elderly Rights *

Clear

Blood-borne Pathogens *

Clear

Abuse Neglect and exploitation information *

Clear

I confirm that I have read and fully understand this document, and by confirming constitutes a legally binding signature *

Clear

I, ______________, hereby authorize Click Clinician Inc. to investigate my background and qualifications for the purpose of evaluating whether I am qualified for the contract position for which I am applying (PT, OT, PTA, COTA). I understand that Click Clinician Inc. will utilize an outside firm or firms to assist in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company's choice. I also understand that I may withhold my permission and that in such a case, no investigation will be done, and my application for employment will not be processed further.

Background Check Authorization Signature *

Clear

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