Can the application be signed electronically?

Yes. Electronic signatures are generally valid under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted. However, certain categories such as wills and court orders are excluded; check facility policy and state law for any exception before accepting an e-signature.

What authentication is recommended for signers?

Use at least email and consider SMS or knowledge-based verification for higher assurance. For access to PHI or high-risk permissions, deploy stronger authentication such as multi-factor or ID credential analysis and record the method in the audit log.

Is HIPAA compliance required for this form?

If the application collects or grants access to protected health information, HIPAA applies. Facilities must implement safeguards, execute a Business Associate Agreement with vendors handling PHI, and retain records per 45 CFR §164.530(j). Consult your privacy officer for specifics.

Do I need a notary or witnesses for this form?

Not typically for a companion application unless state law or facility policy requires it. Certain legal authorizations may require notarization or witnesses; check state notary and witness rules or the facility's legal team before assuming no notarization is needed.

How can the application be updated or revoked?

Submit a revised application signed by the patient or authorized representative. To revoke companion authorization, obtain a signed written revocation or a new document that supersedes prior consent, and retain both versions for auditability and continuity.

Where should completed applications be stored?

Store signed records in the facility's secure record system or EMR with access controls and audit trails. If PHI is present, follow HIPAA safeguards and retention schedules and maintain exportable PDF/A copies for long-term preservation.

Electronic Signature
Templates
Healthcare
Healthcare Companion Application

Healthcare Companion Application

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Healthcare Companion Application

Complete this application fully and legibly. Submission of this application authorizes the organization to verify information provided, conduct background checks where permitted by law, and contact references and prior employers. Incomplete or false information may disqualify the applicant.

Position and Availability

Position Applied For Preferred Start Date Availability (select days and describe hours)

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Applicant Information

Full Legal Name

Date of Birth:

Gender:

Preferred Pronouns:

Address

Phone:

Email:

Emergency Contact

Name

Relationship:

Phone:

Certifications, Licenses & Training

Please indicate current certifications. Provide certificate numbers and expiration dates where applicable.

CPR First Aid CNA Driver's License Other

If applicable, list certificate name, number and expiration date

Employment History (Last 5 Years)

Provide most recent employer first. Include periods of unemployment and volunteer work relevant to caregiving.

Employer 1 — Name & Address

Job Title:

Dates Employed:

Duties and Reason for Leaving Employer 2 — Name & Address

Job Title:

Dates Employed:

Duties and Reason for Leaving

References (Non-Relatives)

Reference 1 — Name, Relationship, Phone Reference 2 — Name, Relationship, Phone

Health & Immunization

Applicants must disclose conditions that would interfere with safe performance of companion duties and provide immunization information for client safety.

Current Medications Allergies (Medication, Food, Environmental)

Recent TB test

Flu vaccine this season

Criminal Background & Driving Record

Answering yes to the following does not automatically disqualify an applicant. Provide complete details where applicable. The organization may obtain driving record and criminal history checks where permitted by law.

No criminal convictions to disclose Yes — explain below

Driving record with no major violations Driving violations to disclose

Skills, Duties & Client Preferences

Describe relevant skills, caregiving experience, and client types you are comfortable serving Are you able to assist with the following? (check all that apply)

Mobility assistance (transfers, ambulation) Personal care (bathing, dressing) Meal preparation Medication reminders (non-administering)

Authorization & Certifications

By signing below, I certify under penalty of perjury that the information contained in this application is true, complete and correct. I authorize the organization to contact references, prior employers, educational institutions, licensing bodies, and to conduct criminal background, motor vehicle and other checks as permitted by law. I release all parties from liability for furnishing information. I understand that misrepresentation or omission of facts may result in denial of appointment or termination.

I acknowledge my obligation to maintain client confidentiality and to comply with applicable privacy and health information protection laws. I understand that I must immediately report changes in my ability to perform duties safely, including health conditions or convictions that affect suitability.

Authorization for Release Expires On

I acknowledge receipt of privacy and confidentiality responsibilities

Applicant Statement

I understand that this application does not guarantee placement or employment. I agree to abide by applicable policies, complete required orientation and training, and provide proof of identity and eligibility to work if required.

Additional Information

Applicant Name:

Signature:

Date:

What the Healthcare Companion Application Is

The Healthcare Companion Application is a standardized form used by medical facilities, long-term care providers, and home health agencies to register an individual who will assist a patient as a companion, caregiver, or authorized visitor. The application documents the companion's identity, relationship to the patient, scope of permitted activities, emergency contact information, and any special training or clearances required by the provider. It also captures consent for limited access to nonclinical patient information where necessary. Proper completion helps facilities assess risk, preserve patient privacy under HIPAA, and maintain visitor or caregiver records for operational and legal purposes.

Why a Completed Application Matters

A completed Healthcare Companion Application documents authorization, clarifies responsibilities, and supports compliance with patient privacy and facility policies. It reduces ambiguity about access rights, helps facilities manage infection control and credential verification, and provides a clear record for incident investigation or audit.

Who Typically Fills Out and Manages This Form

Common users include medical records teams, nursing supervisors, social workers, and designated companions who complete the form.

Hospital admitting staff who need to authorize companion access and record identification.
Long-term care facility administrators managing frequent visitors, respite caregivers, and in-home aides.
Patients or legal representatives completing consent and delegating limited access for care coordination.

Use by the appropriate role ensures the form is complete, verified, and retained according to policy.

Step-by-Step: Complete and Submit the Application

Follow these steps to complete the Healthcare Companion Application accurately and securely, including verification, consent, and record retention instructions.

01

Prepare Documents: Gather ID, patient authorization, and proof of clearance.
02

Complete Form: Enter required fields clearly and avoid abbreviations.
03

Verify Identity: Match companion ID to provided names and DOB.
04

Submit & Store: Send to facility and retain a date-stamped copy.

Essential Sections to Include in a Professional Application

Core sections of the Healthcare Companion Application define identification, authorization scope, emergency contacts, health and training disclosures, facility rules, and consent for limited information access.

Identification

Enter full legal name, date of birth, government ID number or type, and current address. Include copy of ID and preferred contact method for verification and future correspondence.

Authorization Scope

Specify permitted activities such as visitation hours, assisting with nonmedical tasks, transporting the patient, and whether medication reminders or clinical care tasks are authorized explicitly.

Health Disclosures

Record relevant health screenings, vaccination status if required, recent exposures, and any training certificates. Facilities may require background checks or additional screening based on risk assessment.

Emergency Contacts

List primary and secondary emergency contacts with relationship, phone numbers, and authorization to make decisions if the companion is unavailable. Include alternates for after-hours reachability.

Facility Rules

Note any facility restrictions such as vaccination requirements, PPE use, visiting schedules, designated areas, and prohibited activities to ensure compliance and safety at all times.

Consent & Privacy

Specify patient consent for limited access to nonclinical records, data sharing permissions, and acknowledgment of HIPAA protections; include signature block and date for legal validity.

Key Information Elements to Capture

Patient Name: Enter full legal name as ID.

Companion Name: Full legal name and relation.

Date of Birth: Enter as MM/DD/YYYY format.

ID Document: Type and number with copy.

Contact Info: Phone number and email

Signature: Signature and date required

Configure a Digital Workflow for the Application

Configure the digital workflow to capture signatures, conditional fields, authentication, and retention settings for the Healthcare Companion Application.

Field	Configuration
Authentication Method	Email link with optional SMS two-factor code
Field Types	Signature, Initials, Date, Free-text, Checkbox
Conditional Logic	Display companion fields when 'companion required' checked
Retention & Export	Save PDF/A to secure storage and retain audit trail

How the Digital Submission Process Works

This process shows how an applicant completes, signs, and submits the Healthcare Companion Application and how the facility captures verification and records.

Upload: Attach ID and supporting documents as PDF or image.
Place Fields: Add signature, initials, date, and conditional fields for consent.
Invite Signer: Send a secure signing link; include authentication options.
Archive: Store signed copy with audit log and retention settings.

Platform and Integration Considerations

Use eSignature platforms compatible with PDF/DOCX, integrations, and HIPAA compliance for Healthcare Companion Application processing.

File Types: Supports PDF, DOCX, and plain text
Integrations: Connects to EMR and cloud storage
Authentication: Email, SMS, or SSO options

Typical Timelines and Processing Expectations

Timelines vary by facility but typical processing and verification timeframes for Healthcare Companion Applications fall within several business days; follow facility-specific deadlines for expedited access.

Application Submission Deadline:

Submit before the facility cutoff to avoid delay.

ID Verification Window:

Identity verification typically completes within 1–3 business days.

Background Check Time:

Checks often take 3–7 business days depending on scope.

Facility Approval Period:

Approval can be immediate or require up to 5–10 business days.

Emergency Access Request:

Facilities may grant temporary access within 24–48 hours.

Common Preparation Errors to Avoid

Incomplete identification or mismatched names cause verification delays and may require resubmission, which can postpone companion access and burden administrative staff.
Using vague activity descriptions like 'assist as needed' creates legal ambiguity; specify permitted tasks to protect patient safety and facility liability.
Failing to obtain consent for limited information access can create HIPAA compliance issues; include explicit patient authorization language.
Neglecting to retain signed documents with audit trails risks noncompliance during audits or incident investigations and may increase legal exposure.

Risks and Potential Consequences

Access Denial: Companion may be denied entry.

Service Delay: Care coordination can be delayed.

HIPAA Risk: Unauthorized access may trigger HIPAA investigation.

Operational Burden: Staff time increases for follow-up.

Legal Exposure: Facility faces potential liability.

Form Rejection: Incomplete forms will be returned.

Real-World Examples of Companion Application Use

These examples show how organizations adapted companion application workflows to reduce paperwork and preserve audit trails while protecting privacy.

Fertility Centers of Illinois

A clinic used a companion application workflow to register authorized companions for patients undergoing treatment, reducing in-person paperwork.

Digital signing simplified authorizations and verification.
The airSlate SignNow team has been exceptional, responsive, the API has been great, and we're extremely happy that we chose airSlate SignNow as a company. The workflow preserved audit trails and reduced processing time for compliance checks.

Community Hospital

A midsize hospital implemented the companion application to manage visitor permissions during outbreaks and to document clearance status efficiently.

Rapid verification improved infection control.
The digital workflow captured signatures, vaccination attestations, and identity verification results, creating an auditable record that supported infection control decisions and reduced front-desk workload while maintaining patient privacy under facility policies and HIPAA.

Comparing signNow and Common eSignature Vendors

This table compares baseline pricing and core capabilities of signNow and common eSignature vendors for Healthcare Companion Application workflows.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial, no card	Varies by vendor and plan	Varies by vendor and plan	Varies by vendor and plan	Varies by vendor and plan
Bulk Send	Yes, available on Business Premium and above	Yes, available on select plans	Yes, supported via batch sending feature	Yes, includes bulk send tools	Not available on standard plans
Audit Trail	Yes, includes audit trail and timestamps	Yes, includes audit trail and timestamps	Yes, includes audit trail and timestamps	Yes, includes audit trail and timestamps	Yes, includes audit trail and timestamps
HIPAA Compliant	Yes, HIPAA-compliant with BAA available	Yes, HIPAA support with BAA option	Yes, HIPAA support with BAA	No, HIPAA BAA not provided	No, HIPAA BAA not provided
Envelope Cap	No envelope cap on paid plans	Limit of 100 envelopes per user per year	Varies by vendor and plan	Varies by vendor and plan	Varies by vendor and plan

Frequently Asked Questions and Troubleshooting

Answers to common questions about completing, signing, and managing the Healthcare Companion Application, with compliance and practical guidance.

Need help? Contact support

Can the application be signed electronically?
Yes. Electronic signatures are generally valid under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted. However, certain categories such as wills and court orders are excluded; check facility policy and state law for any exception before accepting an e-signature.
What authentication is recommended for signers?
Use at least email and consider SMS or knowledge-based verification for higher assurance. For access to PHI or high-risk permissions, deploy stronger authentication such as multi-factor or ID credential analysis and record the method in the audit log.
Is HIPAA compliance required for this form?
If the application collects or grants access to protected health information, HIPAA applies. Facilities must implement safeguards, execute a Business Associate Agreement with vendors handling PHI, and retain records per 45 CFR §164.530(j). Consult your privacy officer for specifics.
Do I need a notary or witnesses for this form?
Not typically for a companion application unless state law or facility policy requires it. Certain legal authorizations may require notarization or witnesses; check state notary and witness rules or the facility's legal team before assuming no notarization is needed.
How can the application be updated or revoked?
Submit a revised application signed by the patient or authorized representative. To revoke companion authorization, obtain a signed written revocation or a new document that supersedes prior consent, and retain both versions for auditability and continuity.
Where should completed applications be stored?
Store signed records in the facility's secure record system or EMR with access controls and audit trails. If PHI is present, follow HIPAA safeguards and retention schedules and maintain exportable PDF/A copies for long-term preservation.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now