Parnter Network | BAS Healthcare

Agency's Full Legal Name(Required)

Filled Out By(Required)

Email(Required)

Please List All DBAs Or Subsidiaries That Are Covered Under This Application(Required)

(Enter N/A if not applicable)

Please List All Other DBAs Under Your Parent Organization That Are Not Party To This Application(Required)

(Enter N/A if not applicable)

Vendor Email Address(Required)

City(Required)

State/Region(Required)

Postal Code(Required)

Type Of Business (LLC, Corp, Etc.)(Required)

Federal Tax ID(Required)

State Of Incorporation(Required)

Date

MM slash DD slash YYYY

Main Phone Number(Required)

Website Address(Required)

Number Of Internal Employees(Required)

Number Of Contracted Employees(Required)

Please Provide The Percentage Breakdown Of Support Of The Regions Of The Country That Your Company Currently Staffs - Do Not Exceed 100%.(Required)

Connecticut, Delaware, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont, New Jersey, New York, and Pennsylvania

Midwest(Required)

Illinois, Indiana, Michigan, Ohio, Wisconsin, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota

South(Required)

Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia, Alabama, Kentucky, Mississippi, Tennessee, Arkansas, Louisiana, Oklahoma, and Texas

West(Required)

Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming, Alaska, California, Hawaii, Oregon, and Washington

Gross Annual Sales(Required)

Can You Provide At Least Two Professional References From Clients?(Required)

Yes

PLEASE SELECT HOW YOU HEARD ABOUT THE PARTNER NETWORK:*(Required)

Internet Search

Word of mouth (reputation, current partner, etc.)

Hospital Client

Event - SIA

Other

What Do You Staff? (Check All That Apply)(Required)

Travel

Per Diem

Local

Perm Placement (Direct Hire/Direct Placement)

Government/Federal Contracts

Nurse Staffing

LPN/LVN

CNAs/Home Health Aides, Patient Care Assistants, etc.

Medical Assistants

Allied Staffing

Therapy Staffing

Advanced Practice

Locum Tenens

Non-Clinical Staffing

Nurse Staffing (Check All That Apply)

Case Management

Cath Lab

Critical Care (ICU, Step-down, etc.)

Home Health (Home Health, Hospice, LTAC, etc.)

Medical Surgical (MS, MS/Tele, Tele, etc.)

NICU

Outpatient Clinic

Pediatrics

Surgical Services (OR, PACU, Recovery, etc.)

Utilization Review

Women's Services (Labor and Delivery, Pre/Post-Partum, etc.)

Wound Care

(Select the specialties that you can staff):

Allied Staffing (Check All That Apply)

Cath Lab

Imaging

Lab

Medical Technologist

OR Tech

Pharmacy

(Select the specialties that you can staff):

Allied Staffing (Check All That Apply)

Cath Lab

Imaging

Lab

Medical Technologist

OR Tech

Pharmacy

(Select the specialties that you can staff):

Occupational

Inpatient

Outpatient

School

Physical

Inpatient

Outpatient

School

Respiratory

Inpatient

Outpatient

School

Speech

Inpatient

Outpatient

School

Advanced Practice (Check All That Apply)

Nurse Practitioner

Certified Registered Nurse Anesthetist

Anesthesia Assistant

Physician Assistant

(Select the specialties that you can staff):

Locum Tenens (Check All That Apply)

Neurology

Psychiatry

Family Practice

Cardiology

Gastroenterology

Anesthesiology

Urology

Emergency Medicine

OB/GYN

Hospitalist (Internal Medicine)

Surgery (General, Neuro, Ortho, etc.)

Urgent Care

Radiology

Oncology

(Select the specialties that you can staff):

Non-Clinical Staffing (Check All That Apply)

Administrative

Environmental Services (EVS)

Facilities

Finance/Accounting

Food and Nutrition

Health and Information Management

Human Resources

Information Technology (IT)

Legal

Marketing

Transportation and Logistics

(Select the specialties that you can staff):

Of The Above, What Is Your Primary Area Of Expertise?(Required)

Travel (Nursing, LPN, LVN, CNAs, Medical Assistants, Allied, Therapy)

APP, Locum Tenens

Non-Clinical

(Select the specialties that you can staff):

How to Join

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