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Vendor Application Form for Hand Therapy Services (Form 19B198)

To apply to become a Hand Therapy provider with us, please complete and submit this application form.

This form must be completed in Adobe Acrobat. If you don’t already have Acrobat on your computer, you can download Adobe Acrobat Reader, a free app, from

Please note the form’s functionality will not work properly if the form is opened in an internet browser such as Microsoft Edge or Google Chrome.

To submit the form:

  1. Click the Download PDF button. The form will be copied to the Downloads folder on your computer hard drive.
  2. Open the form in Acrobat by going to your Downloads folder and right-clicking on the PDF file. Select Open with > Adobe Acrobat Reader.
  3. Type your information in the form and attach any additional documents.
  4. Save your form, then click the Submit button at the end of the form.
  5. An email to will pop up. Ensure your completed form is attached, then click Send.
Publication Date: Sep 18, 2023 File type: PDF (2 MB)