New Contractor

New Contractor

  • Contractor Forms

  • Max. file size: 20 MB.
  • Max. file size: 20 MB.
    Copy of form at bottom of page.
  • Max. file size: 20 MB.
    Copy of form at bottom of page.
  • I-9 E-Verify: Will need copy of card(s) for I-9 E-Verify.

  • Max. file size: 20 MB.
  • Max. file size: 20 MB.
  • Contractor Requirements

  • Max. file size: 20 MB.
  • Max. file size: 20 MB.
  • Attach copy of your Professional Liability
    Max. file size: 20 MB.
  • Attach copy of your Professional Liability. If you need to establish your LLC use this link: www.in.gov/sos/business/2428.htm
    Max. file size: 20 MB.
  • Health Information

    As a contractor, you are responsible to provide items below at your own expense.
  • Copy of physical confirming that you are able to perform the essential functions of the job with or without restrictions, and free of communicable disease.
    Max. file size: 20 MB.
  • Copy of Mantoux tuberculin skin test (required), Hepatitis vaccinations, Influenza shot. Please provide copies of any of these that you have.
    Max. file size: 20 MB.
  • Copy of COVID Vaccination Card.
    Max. file size: 20 MB.
  • Copy of COVID waiver application and any supporting documentation.
    Max. file size: 20 MB.
  • Copy of 10-panel drug screen.
    Max. file size: 20 MB.
  • Credentials

  • UniversityGraduation DateDegree 
  • Certification/License or Related CredentialsState if applicable 
  • Drop files here or
    Max. file size: 20 MB.
    • As a contractor, please attach a copy of your business card.
      Drop files here or
      Max. file size: 20 MB.
      • Emergency Contact

        In case of emergency at work please list your emergency contact person.
      • Disclaimers

        Google, Yahoo, Comcast, and any other public email domain is unfortunately insecure for sensitive patient information. If you choose to provide your own secure email address, you will need to present NSI with requested documentation and proof of your secure email.
      • MM slash DD slash YYYY

      W9 Form

      Direct Deposit Form