Job Application

Position Applying For

Employee Information

Personal Information

Last Name

First Name

Middle Name

Address

City

State

Zip

Email Address

Cell Phone Number

Educational Information

High School

College

Business, Technical or Trade Certification

Employment History

Employer Name

Employer Address

Employer City

Employer State

Employer Zip

Employer Phone

Start Date

End Date

Reason For Leaving

Employer Reference Authorization

Yes No

Background & Consent fo Screening

Are you a convicted felon?

Yes No

Explanation

Acceptance

BY MY ELECTRONIC SIGNATURE CERTIFICATION STATEMENT* BACKGROUND DISCLOSURE AND AUTHORIZATION FORM

By checking the box above, I expressly authorize and instruct the consumer reporting agency to perform and release to the company, a Background check Report(s) on me at the request of the company in conjunction with my employment application. I understand that if the company hires me, my consent will apply throughout my employment to the extent permitted by law, unless I revoke or cancel my consent by sending a signed statement to the company.

I understand that, to the extent allowed by law, information contained in my job application or otherwise disclosed by me before, during or after my employment may be utilized for the purpose of obtaining Background Check Reports.

By my signature below, I also authorize the disclosure to the consumer reporting agency information concerning my employment history, education, credit history, motor vehicle history, and criminal history, and all other information the consumer reporting agency deems pertinent by any individual, corporation, or other private or public entity, including without limitation the following: employers, learning institutions, law enforcement agencies, federal, state and local courts, the military, credit bureaus, motor vehicle records, National Sex Offender Registry, Office of the Inspector General, and the other applicable sources.

I further acknowledge that a Fax or photographic copy of this release will be as valid as the original.

I also understand that any false statements or deliberate omissions or false representations on this document or any other document may be grounds for disqualification from employment opportunities or dismissal from the company.

For residents of California, Minnesota, and Oklahoma only: You will be provided with a free copy of any consumer reports or investigative consumer reports on you if you initial the space provided.

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone

AGREEMENTS BY MY ELECTRONIC SIGNATURE, I HAVE READ AND UNDERSTAND THE FOLLOWING AGREEMENTS

ELECTRONIC SIGNATURE CERTIFICATION STATEMENT

Please provide any additional information regarding your accomplishments, career goals, experience, volunteer work, special skills, or education, that, you think would be helpful to us in evaluating your application. I hereby authorize the company, Inc to fully investigate my record and work qualifications either before or during my employment, and to facilitate investigation, I also hereby authorize any persons having knowledge thereof to give such information to the company, upon request.

I certify that all statements made by me on this application are true and correct to the best of my knowledge and belief, and agree that any misrepresentation, falsification or omission of facts thereon shall be sufficient cause to deny my employment or if employed to justify my dismissal.

The company is an equal opportunity employer and does not because of race, creed, color, sex, marital status, age, national origin, handicap, veteran status, or sexual preference.

I understand that the company conducts a full background investigation on all employees, including but not limited to National Sex Offender List, Office of the Inspector General, Criminal background, and credit history.

I understand that any offer of employment is conditional on my ability to establish eligibility under the Immigration Reform and Control act of 1986. A conflict of interest may take overt or covert forms and can represent many situations. However, it is generally understood that a conflict of interest constitutes a situation when the company as a whole or individual representatives of the company, has competing professional or personal obligations or personal or financial interests that would make it difficult for the company or the individual(s) to fairly fulfill the mission, vision and values of the institution. In general, conflicts of interest relate to the potential for self-gain usually, but not always, of a fiscal nature. Potential for self-gain can serve to undermine the judgment or objectivity of licensed independent practitioners, administrators, employees, consultants and designated contractors such that their mission and dedication to the values and activities of the company are compromised. Therefore it is required that any contractual arrangement, partnership, agreement or fiduciary relationship (including employment) entered into by the company and any other party that will affect the mission, vision or values of the company, must respect and abide by the policies, procedures and directives of the company.

Disclosures may include, but are not limited to, relationships, associations or business dealings with vendors, suppliers, organizations or individuals with whom the company may have a contractual relationship.

DEFINITIONS

The term significant financial interest signifies anything of monetary value, including but not limited to, salary or other payments for services (e.g., consulting fees or honoraria); equity interests (e.g., stocks, stock options or other ownership interests); and intellectual property rights (e.g., patents, copyrights and royalties from such rights).

The term does not include:

Salary, royalties or other remuneration.
Income from engagements sponsored by public or nonprofit entities;
Income from service on advisory committees or review panels for public or nonprofit entities;
An equity interest that when aggregated for the investigator and the investigator’s spouse and dependent children, meets both of the following tests: Does not exceed $10,000 in value as determined through reference to public prices or other reasonable measures of fair market value, and does not represent more than a 5% ownership interest in any single entity; or
Salary, royalties or other payments that when aggregated for the investigator and the investigator’s spouse and dependent children over the next twelve months, are not reasonably expected to exceed $10,000.

CONFLICT OF INTEREST STATEMENT*

I understand that while performing my official duties I may have access to information that is classified as either confidential or sensitive or protected health information. Confidential information is information that identifies an individual or an employing unit. Sensitive information may be financial or operational information that requires the maintenance of its integrity and assurance of its accuracy and completeness. Protected Health Information (PHI) means individually identifiable health information that is transmitted or maintained in any form or medium. Confidential, sensitive, protected health information is not open to the public. Special precautions are necessary to protect this type of information from unauthorized access, use, modification, disclosure, or destruction.

I agree to protect the following types of information:

Client information (such as, disability insurance claimants, recipients of public social services, participants of state/federal programs, employers, etc.) * Information about how automated systems are accessed and operate.
Wage earner information and any other proprietary information.
All data elements described as protected health information in HIPAA (Section 164.514)
Operational information (instruction manuals)
I agree to protect confidential and sensitive PHI by:
Accessing, using, or modifying confidential and/or sensitive and/or PHI only for the purpose of performing my official duties
Never sharing passwords with anyone or storing passwords in a location accessible to unauthorized personnel.
Never accessing or using confidential and/or sensitive and/or PHI out of curiosity, or for personal interest or advantage
Never showing, discussing, or disclosing confidential and/or sensitive and/or PHI to or with anyone who does not have the legal authority or the "need to know".
Storing confidential and/or sensitive information in a place physically secure from access by unauthorized persons.
Never removing confidential and/or sensitive and/or PHI from the work area without authorization.
Disposing confidential and/or sensitive and/or PHI by utilizing an approved method of destruction, which includes shredding, burning or certified or witnessed destruction. Never disposing of such information in the wastebaskets or recycle bins.

Penalties:

Unauthorized access, use, modification, disclosure, or destruction is strictly prohibited by State and Federal laws. The penalties for unauthorized access, use, modification, disclosure, or destruction may include disciplinary action up to and including termination of employment and/or criminal or civil action. Each episode of employee discipline regarding the above will be documented.

" I certify that I have read and understand the Confidentiality Statement above."

I also understand that if I have any questions regarding this policy, I should bring them to the attention of my immediate Supervisor.

EMPLOYEE CONFIDENTIALITY*

HIPAA TRAINING

Policy

A. The Company provides training:
B. To each member of the workforce by no later than the compliance date for the covered entity or date of employment whichever is first;
C. Thereafter, to each new member of the workforce within a reasonable period of time after the person joins The Company; and a. To each member of The Company workforce and independent contractors whose functions are affected by a material change in the privacy or security policies or procedures within a reasonable period of time after the material change becomes effective. Workforce means employees, volunteers, trainees, and other persons whose conduct, in theperformance of work for a covered entity, is under the direct control of such entity, whether or not they are paid by the covered entity,
D. The Company documents that the training has been provided. At a minimum, documentation of training shall consist of a signed acknowledgement by the member of the workforce specifying which training has been received and the date the training was taken.
E. The Company will retain the documentation for six years from the date of its creation or the date when it last was in effect, whichever is later.
F. The Company will maintain a training record for each member of its workforce. The training record should include the specific training and the dates the training was received and/or the signed acknowledgement referred to above in Item B. These training records will assist in identifying where supplementary training needs to be conducted should there be changes in the privacy or security regulations.

Below is the certification of training by employee of The Company.

I understand that while performing my official duties I may have access to information that is classified as either confidential or sensitive or protected health information. Confidential information is information that identifies an individual or an employing unit. Sensitive information may be financial or operational information that requires the maintenance of its integrity and assurance of its accuracy and completeness. Protected Health Information (PHI) means individually identifiable health information that is transmitted or maintained in any form or medium. Confidential, sensitive, protected health information is not open to the public.
Special precautions are necessary to protect this type of information from unauthorized access, use, modification, disclosure, or destruction.

I agree to protect the following types of information:

Client information (such as, disability insurance claimants, recipients of public social services, participants of state/federal programs, employers, etc.)
Information about how automated systems are accessed and operate.
Wage earner information • Any other proprietary information.
All data elements described as protected health information in HIPAA (Section 164.514)
Operational information (instructional manuals) I agree to protect confidential and sensitive and PHI by:
Accessing, using, or modifying confidential and/or sensitive and/or PHI only for the purpose of performing my official duties.
Never sharing passwords with anyone or storing passwords in a location accessible to unauthorized persons.
Never accessing or using confidential and/or sensitive and/or PHI out of curiosity, or for personal interest or advantage.
Never showing, discussing, or disclosing confidential and/or sensitive and/or PHI to or with anyone who does not have the legal authority or the "need to know".
Storing confidential and/or sensitive information in a place physically secure from access by unauthorized persons
Never removing confidential and/or sensitive and/or PHI from the work area without authorization.
Disposing confidential and/or sensitive and/or PHI by utilizing an approved method of destruction, which includes shredding, burning, or certified or witnessed destruction.
Never disposing such information in the wastebasket

QPI Healthcare Services™