Employee Intake Form Instructions
Employee Intake Form Instructions
Complete the information below to apply with Best Care. You also need to upload a copy of your Drivers License or State ID, Social Security Card for background study verification, and PCA Certificate. When your background study clears you will receive an invitation to complete your pre-employment paperwork (W4, I9, Direct Deposit, Etc). When you are approved to work you will receive a Start Work Letter. You are not approved to work and not an employee until you receive a signed Start Work Letter from our office.
Application Date
/
Month
/
Day
Year
Date
Number
Job Title
PCA
245D (Waivered Services)
Name
*
First Name
Last Name (Add SR/JR here if applicable)
With which gender do you identify?
*
Male
Female
Non Binary
Intake Person
*
Intake Person Phone
*
Intake Person Email
*
example@example.com
Applicant First Name
*
Applicant Middle Name
*
Applicant Last Name
*
Add SR/JR here if applicable
Middle Initial
Alias/Maiden name, etc
*
Drivers License or ID Number
State of Issuance
*
Expiration Date
-
Month
-
Day
Year
Date
Place of Birth (State)
*
Social Security Number
*
Date of Birth
*
/
Month
/
Day
Year
Date
Age
*
Street Address (Residential Address Required for Application - NO PO Boxes)
*
Apt No
*
City
*
State
*
Zip Code
*
County
*
Email
*
example@example.com
Phone Number
*
Application type?
*
New Hire
Rehire
Are you a previous employee?
*
Yes
No
Have you Lived outside Minnesota in the last five years?
*
No
Yes
If Yes where?
From Year
To Year
Current Name on MN IT'S
Do you work for another PCA agency?
Prefered Method of Contact
Mail
Email
Phone
Who will you be the PCA for?
What is your Relationship to Client?
Notes
Emergency Contact (Name and Phone Number)
UMPI (if requesting reinstatement)
Is the individual 18 years old or older?
*
Yes
No* *May affiliate with only one agency
Date Passed
/
Month
/
Day
Year
Date
PCA CERTIFICATION NUMBER (If Known)
BGS NUMBER or APPLICATION ID
Previously enrolled with MCO
Yes
No
Group Affiliation
Yes
No
AGENCY PERSONNEL COMPLETING FORM
*
Draw your initials (AEB or AB etc.)
*
Enter Initials
Clear
Sign your name (I agree to the PCA enrollment requirments and Best Care polices)
Sign
Clear
Upload an image of your Drivers License, Social Security Card, and PCA Certificate.
*
Browse Files
Drag and drop files here
Choose a file
pdf, jpg, jpeg, png, or gif only
Cancel
of
Review our Policy and Procedure Manual
Please acknowledge that you have received and reviewed our policy an procedure manual.
I have received and reviewed the Best Care policy and procedure manual.
Medical reimbursement plan.
I do NOT wish to participate in the tax-free, employer sponsored MEC Plan.
Check if signing electronically
My name as typed in the signature field is my legally binding signature.
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