Step 1: Basic Information

Agency Name *

Agency Type * Select Type Hospice Home Health

Owner/Director Name *

Phone No. *

Agency Email *

Password *

You agree to receive SMS messages from ACTA for connecting with skilled clinicians for per diem assignments and shift opportunities. You may reply STOP to opt-out at any time. If you need help please reply HELP. Messages and data rates may apply. Message frequency will vary. To know more read our Privacy Policy.

You agree to receive Emails/telephone calls from ACTA for connecting with skilled clinicians for per diem assignments and shift opportunities, in accordance with our Terms of Use and Privacy Policy. You can click on UNSUBSCRIBE link in any of our Emails to stop getting further communication.

Password must contain:

Minimum 8 characters

At least lowercase letter (a-z)

At least uppercase letter (A-Z)

At least number (0-9)

Next

Step 2: Email Verification

Verify your Email Id to proceed further.

Email OTP *

Verify Resend OTP

Step 3: Complete Registration

Provide additional information to complete your agency sign up.

Address Line 1 *

Address Line 2

City *

Zip Code *

State * Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

County * First select a state

NPI No. *

Issued Date *

Upload NPI Document * Only PDF files are allowed (Max: 5MB)

Dept. of Health License No. *

Expiration Date *

Upload License Document * Only PDF files are allowed (Max: 5MB)

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