Enter Your Personal Data

Work Experience

List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment. Attach additional sheet(s) if necessary.

Work Experience 2

Our agency is required to screen all employees and subcontractors in order to determine if those individuals and entities were excluded from participation in federal healthcare programs. The office manager prior will conduct the OIG screening to hiring and on before the fifth of every month. The OIG results will be obtain by searching both federal and Texas LEIE websites listed below. Texas Health and Human Service Commission- OIG list of Excluded individuals/ Entities online searchable database: Https://www.oig.hhsc.state.tx.us/exclusion/search.aspx

HHS-OIG Excluded Individuals/ Entities online searchable database: https://www.oig.hhs.gov/fraud/exclusion.asp.

All OIG results will be stored in one separate binder from personnel files and will be securely stored in a locked compartment.

Our office manage is aware that when a provider is excluded federal health care programs are generally prohibited from paying for any items furnished, ordered, or prescribed by excluded individuals or entities.

If the office manager becomes aware of anyone that are listed on the exclusion list, the office managers will report any discovered information to HHSC-OIG using the self-report mechanism at: https://oig.hhsc.state.tx.us/ ProviderSelfReporting/SelfReporting.aspx. https://e-verify.uscis.gov/web/Login.aspx.

The agency will maintain documentation for a minimum of six years. Documentation will included the following elements: Date of the federal and state database and searches; First and last names and date of birth of all employees and contractors subject to LEIE searchrequirements; Whether or not the employee/contractor appeared in the federal/state LEIE database; Date any excluded employee/contractor was self-reported to HHSC-OIG; Copy of self-report; and Printed name(s) and signature of staff responsible for completing the monthly searches. By signing below I am stating that I have been informed of the OIG search and am giving permission for Incarnation Home Health Services, Inc. to run the required OIG search prior to employment and on a monthly basis’s therefore after my employment.

I acknowledge that a Computerized Criminal History (CCH) check will be performed by accessing the Texas Department of Public Safety Secure Website and will be based on name and DOB identifiers I supply. (This is not a consent form Authorityfor this agency to access an individual’s criminal history data may be found in Texas Government Code 411; Subchapter F.

Name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history, therefore the organization conducting the criminal history check is not allowed to discuss with me any criminal history record information obtained using this method. Theagency may request that I have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search. Once this process is completed the information on myfingerprint criminal history record may be discussed with me.

In order to complete the process I must make an appointment with the Fingerprint ApplicantServices of Texas (FAST) as instructed online at www.txdps.state.tx.us /Crime Records/Review of Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full and complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $24.95 to the fingerprinting services company.

(This copy must remain on file by your agency. Required for future DPS Audits)

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Your withholding is subject to review by the IRS.

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. 

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

(Fields next page must be completed and signed when preparers and/or translators assist an employee in completing Section 1

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.