Fast Chart Qualification Form

Step 1 of 3

Please complete each of the following questions. Questions marked with " * " are required. You must complete all required fields before you will be able to submit the form to Fast Chart. Please review our Independent Contractor Requirements before completing this form.

Have you read our Independent Contractor Requirements?*

Yes
No

Full Name*

Type your full name in this box

Email*

Primary Phone Number*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

How did you hear about Fast Chart?*

Referring Fast Chart MT name

Total hours per week*

Sunday*

What time Sunday?

Monday*

What time Monday?

Tuesday*

What time Tuesday?

Wednesday*

What time Wednesday?

Thursday*

What time Thursday?

Friday*

What time Friday?

Saturday*

What time Saturday?

Have you worked from home before?

Yes
No

What is your reason for wanting to work from home?

What version of Microsoft Office/Word do you have currently installed?*

Which version of Windows do you have currently installed?*

Which type of internet connection do you use?*

Which edition of the AAMT Book of Style do you have?*

When will you be available to begin work as an Independent Contractor?*

Have you previously performed any work with Fast Chart, Inc.?*

Yes
No
Unsure

If the answer is yes, how long ago?

Step 2 of 3

Please indicate your level of transcription experience (Number of years) in each field:

How much DocQscribe experience do you have?

How much EditScript experience do you have?

How long have you transcribed in a clinical environment?

None
Up to 2 years
2-5 years
>5 years

How long have you transcribed in a hospital enviroment?

None
Up to 2 years
2-5 years
>5 years

Cardiology

Consults

Discharge Summaries (Clinical)

Discharge Summaries (Hospital)

Emergency Department

Endocrinology

ENT

Family Practice

Gastroenterology

General Surgery

Hematology

Hepatology

History & Physicals

Internal Medicine

Nephrology

Neurology

OB/GYN

Oncology

Operative Notes

Ophthalmology

Orthopedics

Physical Therapy

Plastics

Psychology

Pulmonary

Radiology

Rehab (Hospital)

Rheumatology

Urology

Do you have experience in specialties that are not listed? If so, list them in the space provided

Step 3 of 3

Please upload your résumé OR paste it in the allotted area below

Choose a résumé file to upload

Or paste your résumé in the space provided