Official SealSan Joaquin County Human Resources Division


#0123-RO1010-01
Supplemental Questionnaire

Last Name
First Name

1.

To qualify, you must possess three years of experience performing insurance billing, collections, or accounts receivable in a hospital environment within the last five (5) years.
2.

If you meet this requirement, please select the type of hospital experience you possess which qualifies:
Hospital Insurance Billing
Hospital Collections
Hospital Accounts Receivable
None of the above
3.

Please provide the name of the hospital where you were employed:
4.

Please provide the dates of employment (to qualify, the experience must have been within the last 5 years):