New Clinician - Onboarding

Training Session:

After completing this form and the New Clinician - Onboarding Paperwork Checklist (located on the SD Team New Clinician - Onboarding page), please email Rebeka at reception@seeddigging.com to schedule a time/date that you will be able to meet to walk through our EMR and email platforms (usually lasts an 1.5 - 2 hours).

Name:

First Name

Middle Initial

Last Name

Add a new record for each title

Date of Birth:

Date of Birth

Address:

Street Address

City

State

Zip Code

Phone Number:

Phone Number

Alternate Phone Number

E-Mail:

E-Mail Address

Alternate E-Mail Address

DL:

Drivers' License Number

Please bring in a copy of your Drivers' License to your training session. You may also email a copy to reception@seeddigging.com (Please note: This MUST be a PDF or Word document ONLY).

SSN:

Social Security Number

9 Digits, No Dashes

Please bring in a copy of your Social Security card to your training session. You may also email a copy to reception@seeddigging.com (Please note: This MUST be a PDF or Word document ONLY).

CV/Resume

Please bring in a copy of your CV/Resume to your training session. You may also email a copy to reception@seeddigging.com (Please note: This MUST be a PDF or Word document ONLY).

Licensure Type

Please select your current licensure type below.

Intern LPC/LAC

Credentials:

LPC/LAC Licenses Number

Expiration Date

NPI Number

Please bring in a copy of your LPC/LAC licenses to your training session. You may also email a copy to reception@seeddigging.com (Please note: This MUST be a PDF or Word document ONLY).

Council for Affordable Quality Healthcare

CAQH Profile Number

Liability Insurance:

Please note: Seed Digging, PLLC must be included on the policy.

Company Name

Policy Number

Begin Date

End Date

Please bring in a copy of your liability insurance to your training session. You may also email a copy to reception@seeddigging.com (Please note: This MUST be a PDF or Word document ONLY).

Workers' Compensation

It is required to have one of the following:

A Certificate of Non-Coverage (AR-A) Obtain Workers' Compensation Insurance

Please fill out an AR-A form using the link below. Then, upload the completed copy to this form.

**The clinician will be responsible for:

having this document notarized and any fees that may be associated
sending to the Arkansas Workers' Compensation Commission
the requested payment for filing

Once the certificate of non-coverage is received, please e-mail a copy to reception@seeddigging.com.

http://www.awcc.state.ar.us/revisedforms/forma_with_aff.pdf

Please bring in a copy of your completed and notarized AR-A form along with payment to your training session.

Please note: Seed Digging, PLLC must be included on the policy.

Please bring in a copy of your Workers' Compensation insurance to your training session. You may also email a copy to reception@seeddigging.com (Please note: This MUST be a PDF or Word document ONLY).

Seed Digging, PLLC Agreement

Sub-Contractor Agreement

Please bring in a signed copy of the sub-contractor agreement to your training session. You may also email a copy to reception@seeddigging.com (Please note: This MUST be a PDF or Word document ONLY).

Intern Agreement

Please bring in a signed copy of the intern agreement to your training session. You may also email a copy to reception@seeddigging.com (Please note: This MUST be a PDF or Word document ONLY).

Website Information

Please email to reception@seeddigging.com prior to your training session:

An "About Me" bio

Please Note: During your training session, a professional photograph will be taken for our website and any marketing materials. Please dress business casual in black, white, or gray.

Professional Photo

Working Schedule

Monday

Tuesday

Wednesday

Thursday

Friday

*By typing your name and date below, you are signing this document electronically. You agree that your electronic signature is the legal equivalent of your manual/handwritten signature on this application. By typing your name and date below you are certify the information you provided on and in connection with this form is true and correct to the best of your knowledge.

Signature

Date

Your information will be encrypted.