Number of Pages: 1
 
Who is it for?
New employee
 
What is it for?
This form serves to authenticate the employee's name (incluing go-by name), signature, and credential/certificate the employee holds
 
Why should you use it?
When electronic signature is used on digital notes/data sheets, a hard copy of the original signature may be required by the licensing agency or payor 
Employee using a name other than the legal name should fill out the form in order for records to be matched to the employee