TNC Onboarding Document

The Neighborhood Clinic · Confidential

Employee Name:

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Employee Information

First Name

Last Name

Start Date

Job Class

Salary / Hourly / 1099

Pay Rate

Location

Email Address (Personal)

Required Employment & Compliance Documentation — Medical Assistant

Valid government-issued photo ID Social Security card or acceptable I-9 documentation Medical Assistant certification / diploma Current BLS / CPR certification (if employee possesses this certification) Any Immunization Records (Practice Managers verify State Requirements for compliance) TB test / QuantiFERON results (within the last 12 months) (if State Requirement)

FNP/LPC — Credentialing Information (Complete only if you are an FNP/LPC)

This section is to be completed by Family Nurse Practitioners (FNPs) and Licensed Professional Counselors (LPCs).

Social Security Number

Date of Birth

APRN / FNP / LPC License Number

APRN / FNP / LPC License Issue Date

APRN / FNP / LPC License Expiration Date

State License Number

DEA Number (LPCs Disregard)

DEA Expiration Date

NPI Number

CAQH ID

CAQH Username

CAQH Password

FOR HR USE ONLY | Received by: _________________________________ Date: _________________

Personal & Identification Info

Copy of Driver's License Copies of all state medical licenses

Federal Provider Information

Copy of DEA Certificate (LPCs Disregard)

Professional Credentials

Copy of Board Certifications (if applicable) Copy of BLS / ACLS Certification (LPCs Disregard) Copies of all post-high school diplomas / degrees CME Documentation for the past two-year cycle

Professional Liability

Current Professional Liability Insurance — Certificate of Coverage Claims History Report from current PLI Carrier

Additional Documentation

Most Recent Flu Vaccination Record

Required System Action in PECOS

Providers must log into their PECOS account and add The Neighborhood Clinic as a Surrogate Organization to allow our administrative team to manage Medicare enrollment and updates on your behalf.

Log into PECOS at https://pecos.cms.hhs.gov

Navigate to 'Manage Surrogacy'

Add 'The Neighborhood Clinic' as a Surrogate Organization

Confirm authorization so the administrative team can manage enrollment updates