Provider Application

Provider Application
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Education
Degree Earned*
Institution Name*
Graduation Date*

MonthDayYear
Date
Clinical Licensure
License Type*
State of Licensure *
License Number *
License Effective Date*

MonthDayYear
Date
License Expiration Date*

MonthDayYear
Date
Copy of License*

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NPI*
Please List Any Specialized Training, Licenses, Certifications, or Relevant Skills*
Position & Availability
Position Applied For*
Where Did You Hear About Us?*
Are you available to work (F/T, P/T, P/D)*

Full-TimePart-Time
Attach Resume

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What is your preferred start date?*

MonthDayYear
Date
Has any License or Certification You Have Held Been Surrendered, Suspended or Revoked for any Reason? *

YesNo
If Yes, Please Explain*
Have You Ever Been Dismissed, Involuntarily Terminated or Forced to Resign from Employment?*

YesNo
If So, Please Explain*
Professional References
Reference 1 Name / Address / Number**
Reference 2 Name / Address / Number**
Reference 3 Name / Address / Number**
If You Have Worked Under a Different Name at Any of the Job(s) Listed, Please Indicate the Different Name and When Used*
I have applied for employment with Doppler Wellness. I authorize investigation of all statements contained in the Application for Employment as may be necessary in arriving at an employment decision. I authorize representatives of Doppler Wellness to obtain pertinent information from my previous employers, references and other persons with knowledge of my work history and background, financial history, education, regulatory or police records, driving records, licensing status or professional designation and character or reputation, and to consider the information provided by the background check when making decisions regarding my employment at Doppler Wellness I authorize all previous employers, references, or other persons having knowledge of my record or myself to release such information to, and hereby release all persons from liability.
Signature*

Clear
Print Name*
Date*

MonthDayYear
Date
Have You Ever Been Convicted of or Pleaded Guilty of Nolo Contendere (no contest) to a Violation of any State, Federal, County or Municipal Law? (Do not include traffic violations)*
If Yes, Please Give Information Regarding the Nature of the Charge, the Date and Location of Conviction and the Final Disposition of the Case*
Applicants are not required to disclose the existence of an arrest, criminal charge or conviction for which records have been "erased." The types of records subject to erasure under New York law are as follows: (a) a finding of delinquency or that a child was a member of a family with service needs; (b) a sentence as a youthful offender; (c) a criminal charge that was dismissed or "nolled"; (d) a criminal charge for which the person was found not guilty; and (e) a conviction for which the person received an absolute pardon. Any application whose criminal records were erased will be considered to have never been arrested and may so swear under oath. I understand that the information provided above will not necessarily result in the rejection of my application, but that the nature of the information will be considered as it relates to the performance of the job duties in question and in light of the requirements of state and federal law.
Signature*

Clear
Date*

MonthDayYear
Date
MALPRACTICE
If the answer to either of the following questions is YES, please provide details below.
Are There Currently any Pending Medical Malpractice Claims that Have Been Made Against You in any State?*
Have there been any settlements or judgments of medical malpractice against you in the last 2 years in any state?
Incident Date

MonthDayYear
Date
Nature of Claim (Type of case, procedure, major allegation, carrier, hospital, other pertinent information)
Signature

Clear
Date

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Facility*
Position*
This form is to be signed by all covered individuals who are at risk for occupational exposure to blood or potentially infectious material. I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B Vaccine, at no charge to myself.

I request immunization, the first vaccination to be administered on.
Date*

MonthDayYear
Date
Signature*

Clear
Date*

MonthDayYear
Date
This position is not a position determined to be at risk of exposure.
Proof of Physical*

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HIPPA

I acknowledge that I have received, reviewed, and understand the policies and procedures related to HIPAA compliance, confidentiality, and infection control precautions. I agree to adhere to these standards as a condition of my role with Doppler Wellness.
Print Name*
Signature*

Clear
Date*

MonthDayYear
Date
Print Name*
DIRECT DEPOSIT
Name*

First NameLast Name
Authorization for Direct Deposit

I hereby authorize Doppler Wellness to initiate automatic deposits to my account at the financial institution listed below. I also authorize Doppler At Home Therapy to initiate withdrawals from this account in the event that an erroneous credit entry is made.

I agree not to hold Doppler Wellness liable for any delay or loss of funds due to incorrect or incomplete information provided by me or my financial institution, or due to an error by my financial institution in depositing funds to my account.

This authorization will remain in effect until Doppler Wellness receives written notice of cancellation from me or my financial institution, or until I submit an updated direct deposit form to the Payroll Department.
Name of Financial Institution*
Routing Number*
Account Number*
Checking*
Savings*
Please Attach a Voided Check*

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Work Authorization
Are you legally authorized to work in the US*

YesNo
Will you now or in the future require sponsorship for employment visa status (e.g., H-1B, TN, O-1)?*

YesNo
Lists of Required Documents

All documents must be UNEXPIRED

Employees may present one selection from List A

or a combination of one selection from List B and one selection from List C.

LIST A

1. U.S. Passport or U.S. Passport Card

2. Permanent Resident Card or Alien

Registration Receipt Card (Form I-551)

3. Foreign passport that contains a

temporary I-551 stamp or temporary

I-551 printed notation on a machinereadable

immigrant visa

4. Employment Authorization Document

that contains a photograph (Form

I-766)

5. For a nonimmigrant alien authorized

to work for a specific employer

because of his or her status:

Documents that Establish

Both Identity and

Employment Authorization

6. Passport from the Federated States of

Micronesia (FSM) or the Republic of

the Marshall Islands (RMI) with Form

I-94 or Form I-94A indicating

nonimmigrant admission under the

Compact of Free Association Between

the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has

the following:

(1) The same name as the passport;

and

(2) An endorsement of the alien's

nonimmigrant status as long as

that period of endorsement has

not yet expired and the

proposed employment is not in

conflict with any restrictions or

limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are

unable to present a document

listed above:

1. Driver's license or ID card issued by a

State or outlying possession of the

United States provided it contains a

photograph or information such as

name, date of birth, gender, height, eye

color, and address

2. ID card issued by federal, state or local

government agencies or entities,

provided it contains a photograph or

information such as name, date of birth,

gender, height, eye color, and address

3. School ID card with a photograph

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish

Identity

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner

Card

8. Native American tribal document

9. Driver's license issued by a Canadian

government authority

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

LIST B OR AND LIST C

1. A Social Security Account Number

card, unless the card includes one of

the following restrictions:

2. Certification of report of birth issued

by the Department of State (Forms

DS-1350, FS-545, FS-240)

3. Original or certified copy of birth

certificate issued by a State,

county, municipal authority, or

territory of the United States

bearing an official seal

4. Native American tribal document

5. U.S. Citizen ID Card (Form I-197)

6. Identification Card for Use of Resident Citizen in the United States (Form I-179) Documents that Establish Employment Authorization

7. Employment authorization document issued by the Department of Homeland Security

(2) VALID FOR WORK ONLY WITH

INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH

DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Form I-9 07/17/17 N Page 3 of 3

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.
W9

Please fill out the form using the IRS.GOV link, download it and upload it at the next step.

https://www.irs.gov/pub/irs-pdf/fw9.pdf

Tip: If the link doesn't work, please right click and open in a new tab or copy the link into a new tab.
UPLOAD W9

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Name (as shown on your income tax return}. Name is required on this line; do not leave this line blank.*
Business name/disregarded entity name, if different from above*
Check the appropriate box for Federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.*

Individual/ Sole Proprietor or single-member LLCC CorporationS CorporationPartnershipTrust/EstateLimited Liability CompanyOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
0 Limited Liability Company. Enter the Tax Classification (C=C corporation, S=S corporation, P=Partnership*
Exempt Payee Code (if any)*
List Account Number(s} Here (optional}*
Exemption From FATCA Code*
Employer ID #*
Signature*

Clear
Professional Liability Coverage
Please Upload Proof of Professional Liability Insurance*

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Name in Print of Provider*
Signature of Provider*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Provider Application

Education

Clinical Licensure

Position & Availability

Professional References

Work Authorization

Professional Liability Coverage