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BB. Join our Team!
This form is for serious inquiries only. If you would like to discuss a possible partnership or role with our organization prior to providing all of your professional information. Please feel free to Drop Us a Line on our homepage www.midwifeme.org Someone will reach out to you within 1-2 business days.
FIRST NAME
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LAST NAME
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DATE OF BIRTH
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EMAIL ADDRESS
*
BEST PHONE NUMBER
*
Title, Credentials and Certifications
What is your full official title and what are your credentials?
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What are your current professional licenses and certifications? (select all that apply)
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RN with Associates Degree
RN with Bachelors Degree
RN with Masters Degree
FNP
WHNP
CNM
Other APRN
Certified Doula
Certified Birth Assistant
Certified Childbirth Educator
Certified Lactation Specialist
Certified Nursing Assistant
Certified Medical Assistant
OTHER
NONE
Please indicate if you have any of the following:
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CPR Certification
NPR Certification
First Aid Certification
OTHER
NONE
Insurance and Reimbursement
Do you have an NPI number?
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YES
NO
MAYBE
Do you have a current malpractice insurance policy?
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YES
NO
MAYBE
Do you have a Medicaid Provider ID?
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YES
NO
MAYBE
Are you In-Network with any insurance companies?
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YES
NO
MAYBE
BB. Join our Team!
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Red Moon Midwifery
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