FACILITY STAFF REQUEST FORM
*

SECTION 1: FACILITY INFORMATION

SECTION 2: CONTACT PERSON

SECTION 3: POSITION REQUEST DETAILS

SECTION 4: SHIFT & SCHEDULE

SECTION 5: FACILITY & PATIENT DETAILS

(Example: experience with EHR systems, specific procedures, etc.)

SECTION 6: CREDENTIAL REQUIREMENTS

SECTION 7: BILLING & RATE INFORMATION

SECTION 8: DOCUMENT UPLOAD

SECTION 9: ADDITIONAL NOTES

SECTION 10: AGREEMENT & SIGNATURE

Signature Block

Acknowledgment Statement:

"By submitting this request, I confirm that I am authorized to request staffing services on behalf of this facility. I understand that Clinical Practice Partners will match qualified candidates based on the requirements provided and that placement is subject to availability, credential verification, and agreed terms."