Medical Coder Application

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

First Date Available *

MM

DD

YYYY

Are you a citizen of the United States? *

Yes

No

If no, are you authorized to work in the US?

Yes

No

Have you ever worked for this company? *

Yes

No

Have you ever been convicted of a felony? *

Yes

No

What Certifications Do You Have?

Mark all that apply:

None

Grandfathered-In Experience

Certified Professional Coder (CPC)

Certified Outpatient Coding (COC)

Certified Inpatient Coder (CIC)

Certified Risk Adjustment Coder (CRC)

Are you vaccinated against Covid-19? *

Yes

No

Which Vaccine Did You Choose?

Pfizer

Moderna

Johnson & Johnson

Available Times to Work: *

Anytime

Morning

Afternoon

Night

Swing/Graveyard