Best Care Employee Application

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
Job Title *

PCA 245D (Waivered Services)
Application type? *

New Hire Rehire
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 *
Are you 18 years old or older? *

Yes No* *May affiliate with only one agency
Street Address (Residential Address Required for Application - NO PO Boxes) *
Apt No
City *
State Abbreviation *
Zip Code *
County *
Email *
example@example.com
Phone Number *
Prefered Method of Contact

Mail Email Phone
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?
Who will you be the PCA for?
What is your Relationship to Client?
Notes
Emergency Contact (Name and Phone Number)
UMPI (if requesting reinstatement)
PCA CERTIFICATE DATE

Month Day Year
Date
PCA CERTIFICATION NUMBER (If Known)
APPLICATION NUMBER
BGS NUMBER
Previously enrolled with MCO

Yes No
Group Affiliation

Yes No
AGENCY PERSONNEL COMPLETING FORM *
Upload an image of your Drivers License, Social Security Card, and PCA Certificate. *

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 electronic signature is my legally binding signature.
Enter your initials (AEB or AB etc.) *
Sign your name (I agree to the PCA enrollment requirments and Best Care polices) *

Sign Clear
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Employee Intake Form Instructions