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New Provider Onboarding Request Form
New Provider Onboarding Request Form
Get in Touch with Mains'l Services
About the Participant
Participant Information
(Required)
First Name
Middle Name
Last Name
Request Type
(Required)
Employee (W-2): Person will be hired and paid through payroll
Vendor: Independent contractor or business providing services
Service Code
(Required)
Pay Rate
Will this employee/vendor provide direct personal care?
(Required)
Yes
No
Are you requiring the live scan?
(Required)
Yes
No
About the Proposed Employee or Vendor
(Required)
First Name
Last Name
Address
Street Address
City
State
ZIP Code
Email
(Required)
Phone
(Required)
About You
If we need additional information from you, someone from our crew will be in contact.
Your Details
(Required)
First Name
Last Name
Your Email Address
Your Phone Number
(Required)
Your Role
(Required)
Participant
Managing Party
Independent Facilitator
Other
If you selected 'Other', please specify here.
Next Steps
Once we’ve received your form, the Mains’l Onboarding Team will review the information provided and contact you if additional information is needed.
You will also be sent onboarding paperwork and helpful information directly to the person(s) listed.