FREQUENTLY USED FORMS
1. IRS Form W-4
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2. Check Copy Request
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3. Aide Visit Note
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4. Employment Verification
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5. Affidavit of
Good Moral Character
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FORMS & PROVIDER APPLICATION
Please find below Provider 'Frequently Used Forms' at Monef Health. These forms have been placed online in an effort to increase the efficiency of our services not only to our clients but to our providers as well. If utilizing one of these forms, please complete the form online (except 'Aide Visit Note') and either fax the completed form to (305) 999-0521 or email to Monef@att.net. Faxed and emailed requests will be documented and prepared but no documents will be released until originals have been received; in other words, bring the original requests upon pickup from the office.
**APPLICATION** The Monef Provider Application is also provided. Please complete online, print, and bring into the office along with all required documents listed below. Make sure to read & acquire all the required items before coming into the office to finalize your application. Call us with any questions and/or concerns.
PROVIDER APPLICATION
PLEASE GATHER THE FOLLOWING DOCUMENTS AND
BRING ALONG WITH THE COMPLETED/PRINTED
APPLICATION (below) TO THE OFFICE:
- Proof of Citizenship
(Voter's ID, Birth Certificate, Passport, Citizen cert., etc.)
- Professional License/HHA Certificate
- CPR Certificate/Card
- Driver's License
- Auto Insurance
- High School Diploma or College Degree
- Malpractice Insurance
- Physical/Medical Exam
- FDLE Level II Background Screening
- Local Criminal Background Screening
- Payroll Bank Deposit Form (optional)
CERTIFICATES
- Domestic Violence
- HIPAA Compliance
- Alzheimer's
- AIDS/OSHA
- Assistance w/Self Medication
- Incident Reporting, Gastrostomy Tube Care, Trach Care (Nurses Only)
- Prevention of Medical Errors (Nurses Only)
For Application
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