LEO Clinic Employment Application

INITIAL ORIENTATION AND ANNUAL CERTIFICATION OF REVIEW

I acknowledge that The Latin Enrichment Organization, LLC d/b/a LEO Clinic and LEO Primary Care has provided me access to its policies, procedures, manuals, bylaws, job expectations, and training requirements. By signing below, I certify that I have reviewed, understand, and agree to comply with all applicable organizational policies, procedures, standards of practice, and regulatory requirements.

This certification applies upon hire, appointment, internship placement, volunteer service, credentialing, privileging, and annually thereafter.

The undersigned acknowledges review and understanding of the following:

I. Initial Orientation Requirements

(Connecticut General Statutes §§17a-22(b), 17a-57(g), and other applicable regulations)

Organizational Policies and Procedures.
Patient Rights – Policy 1.2 (CGS §§17a-550 and 17a-57(h)).
Confidentiality and Privacy Requirements – Policy 1.8.
Abuse and Neglect Reporting Requirements – Policies 1.18 and 1.19 (CGS §§17a-101 through 17a-101q and 17a-57(h)).
Personnel Policies and Procedures Manual (CGS §17a-22(a)).
Volunteer Policies – Policy 1.4 (CGS §17a-57(g)), when applicable.
LEO Primary Care Policies and Procedures Manual.
LEO Primary Care Medical Staff Bylaws.
Employee responsibilities to conform to all organizational policies, procedures, ethical standards, and applicable laws and regulations.
II. Ongoing Training and Supervision Requirements

Supervision Expectations and Guidelines – Policy 1.25.
Clinicians shall participate in supervision on a weekly basis unless otherwise approved by the Clinical Director.
Licensed Clinicians shall participate in supervision at least bi-weekly, or as otherwise required by licensure, payer, or organizational standards.
APRNs and Physician Assistants shall participate in supervision with the Medical Director at least monthly.
Prescribing staff shall participate in required medical supervision and consultation meetings.
Employees shall attend regular staff meetings, trainings, and supervision sessions as required by their position and department.
III. Employee Grievance Procedures

Policy 1.31 (CGS §17a-22(b))

Procedures for addressing employee concerns, complaints, and grievances.
Procedures for reporting concerns regarding staff conduct.
Procedures for referral of concerns and recommendations to organizational leadership and the Governing Board, as appropriate.
IV. Annual Employee Evaluation Requirements

Policy 1.26 (CGS §17a-22(b))

Review of employee performance and professional responsibilities.
Review and acknowledgment of current Job Description.
Expectations regarding documentation, preparation of adequate case records, compliance with regulatory standards, and fulfillment of position responsibilities.
Review of any required corrective actions, professional development plans, or competency assessments.
V. Employment and Credentialing Acknowledgments

Receipt and review of the LEO Clinic Policies and Procedures Manual.
Understanding of the LEO Clinic ninety (90) day probationary period for newly hired employees, when applicable.
Review and acknowledgment of Clinical Privileges granted, when applicable.
Agreement to comply with all organizational, professional, ethical, clinical, accreditation, licensing, and regulatory requirements applicable to my position.
Certification

I understand that it is my responsibility to seek clarification regarding any policy, procedure, or expectation that I do not fully understand. I further acknowledge that compliance with these requirements is a condition of employment, appointment, internship placement, volunteer service, credentialing, and/or continued affiliation with The Latin Enrichment Organization, LLC d/b/a LEO Clinic and LEO Primary Care.

By signing below, I certify that I have reviewed the materials identified above, understand their contents, and agree to comply with all applicable policies, procedures, standards, and requirements.

ELECTRONIC COMMUNICATION, ELECTRONIC SIGNATURE, AND TRAINING ATTESTATION AGREEMENT

The Latin Enrichment Organization, LLC d/b/a LEO Clinic and LEO Primary Care

I. Purpose

The Latin Enrichment Organization, LLC (“LEO”) may provide certain notices, disclosures, agreements, policies, forms, onboarding documents, training materials, web links, and other communications (collectively referred to as “Communications”) electronically as part of the employment, contracting, credentialing, onboarding, enrollment, re-enrollment, or affiliation process.

This Agreement establishes the employee’s, contractor’s, volunteer’s, intern’s, or provider’s consent to receive Communications electronically and to utilize electronic signatures in conducting business with LEO.

II. Electronic Consent and Acknowledgment

By signing this Agreement, I acknowledge and agree that:

I have carefully reviewed and understand this Agreement in its entirety.
I consent to receive Communications electronically rather than in paper format.
I consent to the use of electronic signatures, electronic records, and electronic transactions in my relationship with LEO.
I understand that my electronic signature shall have the same legal force and effect as my handwritten signature.
I agree to be bound by all electronically executed documents, acknowledgments, agreements, policies, forms, and Communications.
I agree that electronic records may be used to document my receipt, review, acknowledgment, completion, and acceptance of required forms, policies, training materials, and organizational requirements.
I acknowledge that this Agreement is intended to comply with the federal Electronic Signatures in Global and National Commerce Act (“ESIGN Act”), the Uniform Electronic Transactions Act (“UETA”), and all other applicable federal and state laws governing electronic records and signatures.
III. Hardware and Software Requirements

To access, review, sign, and retain electronic Communications, I understand that I must have access to:

A computer, tablet, or mobile device with internet connectivity.
A current web browser capable of supporting secure encrypted connections.
The ability to access and view HTML-based content.
The ability to open and review PDF documents.
JavaScript enabled within my browser settings.
Sufficient electronic storage space to save Communications and records.
Access to a printer if I choose to print copies of Communications for my records.
I understand that it is my responsibility to maintain the equipment and software necessary to access electronic Communications.

IV. Record Retention and Access

LEO may maintain Communications electronically as part of its official business records.
Paper copies may not be routinely provided unless specifically requested or otherwise required by law or organizational policy.
I may download, print, or save copies of Communications for my personal records prior to or following completion of the onboarding process.
I understand that electronically maintained records may be relied upon by LEO for regulatory, accreditation, employment, credentialing, legal, and business purposes.
V. Refusal or Withdrawal of Consent

I understand that participation in electronic Communications and electronic signature processes is voluntary.
I may refuse to provide electronic consent; however, doing so may require the completion of onboarding, employment, credentialing, enrollment, and other business processes through paper documentation.
I may withdraw my consent to receive electronic Communications at any time by providing written notice to:
Human Resources Department
The Latin Enrichment Organization, LLC
Phone: (860) 249-0975 Ext. 0

Withdrawal of consent shall not affect the validity, enforceability, or legal effect of any Communication, agreement, acknowledgment, or signature executed prior to the withdrawal of consent.
VI. Behavioral Health Clinician Training Attestation

For employees, contractors, providers, interns, and clinicians subject to enrollment, credentialing, or re-enrollment requirements, I certify that I have completed, reviewed, and understood all required training materials and documentation applicable to my position.

I further attest that I have:

Viewed and completed the required Behavioral Health Clinic Training Program.
Reviewed all required Behavioral Health Clinic training materials, presentations, manuals, policies, and supporting documentation.
Reviewed the applicable Carelon Behavioral Health of Connecticut enrollment and participation requirements.
Reviewed and completed the “Attestation for Behavioral Health Clinician Groups and Solo Clinicians in Independent Practice,” when applicable.
Reviewed and understand all applicable state and federal laws, regulations, payer requirements, credentialing standards, enrollment agreements, and compliance obligations governing my role.
Completed and reviewed all required TCORS training materials and supporting documentation.
Reviewed and understood the TCORS Medicaid compliance training requirements and related guidance.
Agree to comply with all organizational policies, payer requirements, documentation standards, confidentiality requirements, ethical obligations, and regulatory requirements applicable to my position.
VII. General Certification

By signing below, I certify that:

I have read and understand this Agreement.
I have had the opportunity to ask questions regarding its contents.
I understand that my electronic signature is legally binding.
I consent to conduct business electronically with The Latin Enrichment Organization, LLC.
I certify that all required training, onboarding activities, acknowledgments, and attestations identified herein have been completed to the best of my knowledge.
I understand that falsification of any attestation or acknowledgment may result in disciplinary action, termination of employment or affiliation, reporting to regulatory authorities, or other corrective action as appropriate.

____

TITLE IX RESPONSIBLE EMPLOYEE ACKNOWLEDGMENT AND REPORTING OBLIGATION FORM

The Latin Enrichment Organization, LLC d/b/a LEO Clinic and LEO Primary Care

I. Purpose

The Latin Enrichment Organization, LLC (“LEO”) is committed to maintaining a safe, respectful, and non-discriminatory environment for patients, employees, interns, volunteers, contractors, students, visitors, and affiliated partners.

As part of this commitment, certain employees are designated as Responsible Employees under LEO’s Sexual Misconduct and Title IX Policies. Responsible Employees play a critical role in identifying, reporting, and responding appropriately to concerns involving sexual misconduct, sexual harassment, sexual violence, gender-based discrimination, stalking, dating violence, domestic violence, retaliation, and other conduct prohibited under organizational policy and applicable law.

II. Responsible Employee Designation

I acknowledge that I have been designated as a Responsible Employee under LEO’s Sexual Misconduct and Title IX Policies.

As a Responsible Employee, I understand that I have specific reporting obligations and responsibilities when I become aware of information that may involve prohibited conduct.

III. Review of Policy

I acknowledge that I have received access to, reviewed, and understand the:

Title IX and Sexual Misconduct Policy
contained within the LEO Employee Handbook and related organizational policies and procedures.

I understand that it is my responsibility to remain familiar with the requirements of these policies and any future revisions.

IV. Mandatory Reporting Responsibilities

As a Responsible Employee, I understand that I am required to:

Promptly report any known, suspected, observed, disclosed, or reasonably believed incident of sexual misconduct, sexual harassment, sexual violence, gender-based discrimination, retaliation, stalking, dating violence, domestic violence, or other prohibited conduct involving:


Patients;
Employees;
Interns;
Volunteers;
Contractors;
Students;
Affiliated partners; or
Other individuals participating in LEO programs or services.
Make such reports to a designated Title IX Coordinator, Deputy Title IX Coordinator, Human Resources Representative, Executive Leadership Team Member, or other designated reporting authority as identified by organizational policy.
Submit reports as soon as reasonably possible and no later than twenty-four (24) hours after becoming aware of the concern, unless circumstances require more immediate action.
Report concerns even when:


No formal complaint has been filed;
Information is incomplete;
The individual is uncertain about pursuing a complaint;
The individual requests that no action be taken; or
The Responsible Employee has reason to believe misconduct may have occurred.
V. Confidentiality Limitations

I understand that, as a Responsible Employee:

I am generally not permitted to promise complete confidentiality regarding reports of sexual misconduct.
If an individual discloses information that may involve prohibited conduct, I must advise them that I am required to report the information to the appropriate Title IX representative.
Although reporting is required, LEO will make reasonable efforts to protect privacy and maintain confidentiality to the fullest extent permitted by law and organizational policy.
VI. Response to Disclosures

If an individual discloses information regarding possible sexual misconduct, I understand that I should:

Listen respectfully and professionally.
Inform the individual that I am a Responsible Employee and am required to report the information.
Explain that reporting helps ensure access to available resources, support services, and protective measures.
Inform the individual that confidential and supportive resources may be available through LEO and community-based providers.
Direct the individual to available information regarding rights, resources, reporting options, and support services.
Avoid conducting my own investigation or making determinations regarding responsibility.
Promptly notify the appropriate Title IX Coordinator or designee.
VII. Immediate Safety Concerns

I understand that if there is reason to believe that any person may be at immediate risk of harm, I must take appropriate action, including:

Contacting emergency services (911) when necessary.
Notifying organizational leadership or designated emergency contacts.
Following organizational emergency response and safety procedures.
Taking any other actions required to protect the health, safety, and welfare of affected individuals.
VIII. Consultation and Questions

I understand that I may consult with the Title IX Coordinator, Deputy Title IX Coordinator, Human Resources Department, Compliance Department, or Executive Leadership regarding questions about:

Reporting obligations;
Sexual misconduct concerns;
Confidentiality requirements;
Supportive measures;
Appropriate responses to disclosures; or
Organizational Title IX procedures.
IX. Certification

By signing below, I certify that:

I have received and reviewed the LEO Title IX and Sexual Misconduct Policies.
I understand my responsibilities as a Responsible Employee.
I understand my obligation to report concerns involving sexual misconduct and other prohibited conduct.
I understand the limits of confidentiality associated with my role.
I agree to comply with all reporting requirements, organizational policies, and applicable laws.
I understand that failure to fulfill my reporting obligations may result in corrective action, disciplinary action, or other consequences consistent with organizational policy and applicable law.

DIRECT DEPOSIT AUTHORIZATION AGREEMENT

The Latin Enrichment Organization, LLC d/b/a LEO Clinic and LEO Primary Care

I. Employee Information

Employee Named above

II. Direct Deposit Documentation Requirements

To establish direct deposit, employees must provide documentation verifying the routing and account information for the financial institution designated below.

Checking Accounts

Employees must provide one (1) of the following:

A voided check issued by the financial institution;
A document printed from the employee’s online banking account displaying:


ACH Routing Number; and
Account Number; or
A verification letter from the financial institution containing:


Employee name;
ACH Routing Number; and
Account Number.
Savings Accounts

Employees must provide one (1) of the following:

A bank statement displaying:


ACH Routing Number; and
Savings Account Number; or
A document printed from the employee’s online banking account displaying:


ACH Routing Number; and
Savings Account Number.
Unacceptable Documentation

The following documents will not be accepted as proof of account information:

Deposit slips;
Deposit forms;
Handwritten account information;
Incomplete banking documents; or
Any document that does not clearly identify the ACH routing number and account number.

III. Banking Information

Primary Financial Institution

IV. Authorization for Direct Deposit

I hereby authorize The Latin Enrichment Organization, LLC d/b/a LEO Clinic and LEO Primary Care (“LEO”) to initiate electronic direct deposits of wages, reimbursements, and other authorized payments to the financial institution and account identified above.

I further authorize the financial institution to accept and credit such deposits to my account.

This authorization shall remain in effect until revoked in writing by me and acknowledged by the Human Resources and/or Payroll Department.

V. Authorization for Corrections and Adjustments

I understand and agree that if an overpayment, duplicate payment, erroneous deposit, payroll adjustment, or other correction becomes necessary, LEO is authorized to initiate debit entries, reversing entries, or other lawful adjustments to correct the transaction in accordance with applicable federal and state laws.

I authorize my financial institution to honor such corrective transactions when permitted by law.

VI. Returned or Rejected Deposits

I understand that if my financial institution rejects, returns, or is otherwise unable to process an electronic deposit due to inaccurate account information, account closure, account restrictions, or any other reason beyond the control of LEO:

LEO shall not be responsible for any fees, penalties, or losses incurred as a result of the rejected transaction.
Supplemental or replacement payments may not be issued until the rejected funds have been returned to LEO and verified by the Payroll Department.
It is my responsibility to provide accurate and current banking information and to immediately notify Human Resources or Payroll of any account changes.

VII. Processing Time

I understand that:

Direct deposit activation may require a processing period of up to ten (10) business days or up to two (2) payroll cycles, whichever is longer.
During the implementation period, payroll payments may be issued through an alternative payment method authorized by LEO.
Changes to banking information may also require a processing period before becoming effective.

VIII. Employee Certification

By signing below, I certify that:

The banking information provided is accurate and complete.
I am an authorized account holder or have legal authority to authorize deposits into the account identified above.
I have reviewed and understand the terms of this Direct Deposit Authorization Agreement.
I agree to notify LEO immediately of any changes to my banking information.
I understand that providing false or inaccurate information may delay payment processing.

OTHER REQUIREMENTS

1. Note that privileges granted may only be exercised at LEO Clinic that have the appropriate equipment, license, staff, and other support required to provide the services defined in this document. Site-specific services may be defined in Clinic or department policy.
2. This document defines qualifications to exercise clinical privileges. The applicant must also adhere to any additional organizational, regulatory, or accreditation requirements that the organization is obligated to meet. This class includes privileges for uncomplicated, basic procedures and clinical application of cognitive skilIs. Providers applying for privileges in this class will be graduates of approved medical/primary/pediatric Medicine schools or licensed schools for physician assistants or nurse practitioners. Providers will be properly licensed, and have demonstrated skills in appropriate general medicine practice.