New Technician Setup Form

"*" indicates required fields

Name*
Your Gender*

Clinic Information

(First date treating patients)
MM slash DD slash YYYY

Criminal Conviction/Termination Disclosures

The following questions are required by Forward Health/Medicaid to complete the enrollment process. You are the "applicant".
Has the applicant ever been convicted of a criminal offense related to their involvement in any Federal health care program?*
Has any person or entity having an ownership or control interest in the applicant ever been convicted of a criminal offense related to that person's or entity's involvement in any Federal health care program?*
Has any agent of the applicant ever been convicted of a criminal offense related to that person's involvement in any Federal health care program?*
Has any managing employee of the applicant ever been convicted of a criminal offense related to that person's involvement in any Federal health care program?*
Has the applicant or any person or entity with a 5 percent or greater direct or indirect ownership interest in the applicant been convicted of a criminal offense related to that person's involvement with the Medicare, Medicaid, or title XXI program in the last 10 years?*
Has the applicant been terminated on or after January 1, 2011, under title XVIII of the Social Security Act (Medicare) or under the Medicaid program or CHIP of any other State?*