Provider Information Form

To have a Paradigm Representative contact you please submit the following form or fax your resume to (800) 632 -6079.

Name  

Credentials    Degree 

Do you currently have a Medicare Number    YesNo

Which position are you applying for?   Choose One Licensed Social Worker Psychologist Nurse Practitioner Psychiatrist Management Marketing Customer Support Other

If other please specify   

Please list the location(s) that you are interested in being employed.  Please specify the State as well as the city or the region of that state.  ex.  Western Tenn., or specify Memphis, Tenn.

Location(s)  

Are you willing to relocate?  yes no

How may we contact you? 

Your email address 

Contact Phone Number ()  -    Is this home or work

Address

City            

State  AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY        Zip 

Other information you would like to share

We suggest attaching your resume to this email document or faxing your resume to us at (800) 632-6079.

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