DementiaDevelopmental disabilitiesEntitlements/benefitsEnvironmental and safetyGeriatricsMental healthRehabSign language/hearing or vision impairedSubstance abuse
7. Add degree, license, and/or certification(s)
Degree
Do you have a degree?
NoYes
License
Do you have a professional license?
NoYes
Certification(s)
Do you have any certification(s)?
NoYes
8. Attachments
ResumeAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Exhibit A Attestation FormAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Professional License or DegreeAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Headshot Photo (in JPG format)Accepted file types include .jpg with a maximum size of 5 MB.
Certificate of Professional LIability InsuranceAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Information Security AgreementAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
W-9 FormAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Humana At Home Ownership DIsclosure FormAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Letter of Agreement (submit all pages)Accepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Health Insurance Portability and Accountability Act (HIPPA) Business Associate Agreement (submit all pages)Accepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Certified Care Management (CCM) or Geriatric Care Management Certificate (submit if certified)Accepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Certificate of General Liability (submit if using business name, LLC, or other)Accepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Humana at Home Qualification AssessmentAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Business or Occupational LicenseAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
9. Submittal
Submit my form to
I certify that all of the representations made above are accurate and truthful. I represent that in working with Humana At Home Care Management Network, my company, employees, subcontractors and I agree to abide by the Code of Ethics of our parent profession(s). I affirm that I agree to work in a collaborative team with the other professionals and Humana At Home staff.