*Required

1. Independent contractor information

First name
Middle initial
Last name
Street address
Street address line 2
City
State
ZIP code
Choose address
Send badges to the above addressSend badges to a different address
Date of birth
Email address
Primary phone number
Business phone number
Mobile phone number
Fax number
Driver's license number
State issued
Expiration date
Employment status
Full timePart time

2. Geographical areas served

State served
County or counties served
Distance willing to travel

Note: Care managers are expected to travel at least 25 miles to see a member. 

Services provided (separated by commas if multiple)
Comments
Would you like to add another state?
NoYes
Do you have any prior work history with Humana at Home Care Manager Network?
YesNo

3. Languages spoken

Primary language
Language used to communicate with members
Additional languages (check all that apply)
ArabicArmenianCambodianChineseEnglishFarsiFrenchGermanGreekHaitian; Haitian CreoleHindiItalianJapaneseKoreanLaotianPolishPortugeseRussianSamoanSpanish; CastilianTagalogVietnameseOther language(s)

4. Business information (if applicable)

Business name/doing business as
Fax number
Business phone number
Legal status
Sole proprietorshipLLCOther legal status

5. Business license

Do you have a business license?
NoYes

6. Specializations

Please indicate care management specializations
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.