I, the undersigned, authorize you to release information pertaining to my work skills, experience, or records to Dynamic.
FOR OFFICE USE ONLY: Employee, do not complete this botton section.
An on the job injury will be reported immediately to the Administrator.
Dynamic employees have coverage for work-related illnesses or injuries under Workers' Comp. All medical expenses incurred due to the work-related incident are paid in full along with partial salary payments for the duration of the employee's absent from work. Posted on the employee's bulletin board, is a Bill of Rights for the injured worker.
I, blanks do not have a prior conviction nor have I pled no contest (nolo contendere) for child or adult abuse, neglect, or mistreatment.
It is the policy of Dynamic to ensure the maintenance of a workplace free of any form of employee harassment, including sexual harassment and intimidation. Dynamic expressly prohibits any form of unlawful employee harassment on race, color, religion, sex, national origin, age status, disability, or status as a veteran.
The company maintains a ZERO-TOLERANCE policy for improper interference with the ability of employees to perform their expected job duties.
As an employee/consultant of Dynamic, I agree to keep in confidence all information related to patient geographical data and health history unless requested by the Administrator or designee, to release information to appropriate health care regulatory agencies and/or health care providers.
All information that I may encounter in my line of work related to patient volume, patient referral sources, payroll and salaries, billing/accounts payable/receivable must be maintained in strict confidence and only provided to employees designated by the administrator.
I understand that all codes used for billing and patient registration must be kept confidential.
I understand that breach of confidentiality of information related to patients and Dynamic Hospice and Palliative Care operational procedures will lead to disciplinary actions up to and including termination.
I understand that no patient files, billing information, payroll information, or any other records, forms or data such as Open Packs, Revisit Notes, Policy Manuals obtained at Dynamic is to be loaned, reviewed, or sold to other hospice agencies. This violation will lead to immediate termination and legal action by Dynamic.
This agreement is made and entered into on Dateby and between Dynamic (hereinafter referred to as the AGENCY) and First Name Last Name, (hereinafter referred to as EMPLOYEE).
You will be fully informed about our work policies and procedures during an orientation session. In the meantime, the following information should be useful to you:
Indicate below by your signature and date that you fully understand and intend to adhere to all Dynamic policies and procedures indicated in this form.