LEO Clinic Employment Application

LEO Clinic Employment Application

The Latin Enrichment Organization, Inc Phone 860-249-0975 | Fax: 1-833-968-2486 | 54 Forest Street, Hartford, CT
Time

Hour Minutes

AM/PM Option
Today's Date

MonthDayYear
Date
Full Name

First NameLast Name
Current Home Address

Number and Street NameCity
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Salary
Desired hourly or annual salary
Current Place of Employment

Name of EmployerPosition
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Previous Place of Employment

Name of EmployerPosition
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
What position are you applying for?
Available start date:

MonthDayYear
Date
What is your current employment status?
How do you prefer to submit your resume?
Upload Resume

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Driver's License

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Professional Certification or License (Clinical License, APRN, MD, LPN, etc)

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DEA (if applicable)

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Diploma or Unofficial Transcript (Recent College Transcript)

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Completed Pre-Employment Physical and TB within a year

This will be completed by LEO Clinic Primary Care. Once it is completed provide a copy to your immediate supervisor
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Completed DCF/Mandated Reporter Training

Please see link to complete course here: https://www.proprofs.com/training/course/?title=communitymrt2022_6282bfc17cb23
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Complete W-4

N/A if you are an Intern. For Employee's please click on this link, complete and upload here: https://portal.ct.gov/-/media/DRS/Forms/2023/Withholding/CT-W4_1222Fillable.pdf
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Completed DCF/CPS Background Check

Please click here and complete: https://portal.ct.gov/-/media/DCF/Policy/NEW-fillin-Forms/DCF-3031-Authorization-for-DCF-CPS-BGC-CR-only-Rev-7-2022.pdf
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Complete State Background Check

Please click the link here and complete. Interns must pay the $36 and submit to the State: https://portal.ct.gov/-/media/DESPP/reports_and_records/DPS0846CCriminalHistoryRecordRequestFormRev120117pdf.pdf?la=en&hash=EA50398A227AA13333672A334F53FB6B
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Emergency Contact
Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Special Instructions:
In the event of a medical emergency, please describe any emergency procedures or restrictions on medicationsof which emergency personnel should be aware:
Physician Contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I have voluntarily provided the above contact information and authorize The Latin EnrichmentOrganization and its representatives to contact any of the above individuals on my behalf in the event ofan emergency. Signature
Date

MonthDayYear
Date
Policy Acknowledges Form

My signature below acknowledges that The Latin Enrichment Organization has provided me with a copy of each policy and that I have read, understand, and agree to comply with the expectations, policies and procedures regarding: Initial Orientation (CGS 17a-22(b) and 17a-57(g) (Interns) ● Employee conforms with policy and procedure listed belowPolicy and Procedures ● Patient’s Rights: Policy 1.2 (CGS 17a-550 17a-57 (h)) ● Confidentiality: Policy 1.8. ● Abuse/Neglect: Policy 1.18 and Policy 1.19 (CGS 17a-101-17(a)-57(h)) ● Personnel Policies: Policy and Procedure Manual (CGS 17a-22(a)) ● Volunteer Policies: Policy 1.4 (CGS 17a-57(g) ● LEO Primary Care Policy and Procedure Manual ● LEO Primary Care Medical By Laws On-Going Trainings ● Supervision Expectations/Guideline: Policy 1.25 ● Clinicians must attend supervision on a weekly basis Licensed Clinicians must attend supervision on a bi-weekly basis ● APRNs/PAs must attend supervision with LEO Clinic Medical Director on a monthly basis ● Prescribing staff weekly supervision. ● Provision of regular staff meeting and supervision Employee Grievance Procedures: Policy 1.31 (CGS 17a-22(b) ● Procedure for recommending appointment to the staff and for hearing complaints. regarding the conduct of members, referring the same, with recommendations, to the governing board. Annual Employee Evaluation: Policy 1.26 (CGS 17a-22 (b) ● Employee Job Description (Receipt by Employee) ● Preparation of adequate case records, and more as directed by the job descriptionLEO Clinic Policy and Procedure Manual ● LEO Clinic Probationary Period (90 days from Hire Date) ● Clinical Privilege(s) Granted
I acknowledge that I have read in full and fully understand the above expectations, policies, andprocedures that I have received during my initial orientation. Signature
Date

MonthDayYear
Date
Electronic Communication and Signature Consent Form Consent and Acknowledgement The Latin Enrichment Organization is providing you with certain communications, notices, agreements, forms, web links, and disclosures in writing ("Communications") regarding you being anew hire. Your agreement to this Consent Form confirms your ability and consent 1) to acknowledge this form in its entirety; 2) to receive Communications electronically, rather than in paper form; 3) to the use of electronic signatures in our relationship with you; 4) to be bound by all the terms contained herein regarding the Communications; and 5) to transact in compliance with the federal ESIGN Act to the fullest extent possible to validate our ability to conduct business with you by electronic means.Hardware and Software RequirementsTo access and retain the electronic Communications, you will need the following: ● A computer or mobile device with Internet or mobile connectivity. ● A current web browser (Microsoft Internet Explorer, Mozilla Firefox, Apple Safari, or GoogleChrome) that includes 128-bit encryption. ● Sufficient storage space to save Communications and/or a printer to print them. ● JavaScript enabled in your browser. ● The ability to view Hyper Text Markup Language (HTML) files and read Portable DocumentFormat (PDF) files. Record Retention and Access We will not send you a paper copy of any Communication unless you request it or we other wise deem it appropriate to do so. You may print or save any Communication prior to your onboarding packet being processed.Refusal/Withdrawal of ConsentYou may refuse to consent to receive electronic Communications and use an electronic signature.However, this will result in your new hire process being done with traditional pen and paper forms.You can elect to withdraw your consent to electronic Communication at any time by contacting theHuman Resources Office at (860)249-0975 Ext 0 during business hours. The legal validity and enforceability of prior Communications will not be affected. I have read and understand each and all of the statements above, I agree that I will comply with these statements, and I understand my electronic signature is legally binding. This form certifies that the undersigned employee has received and completed the required training sessions as part of the enrollment/re-enrollment requirements for Behavioral Health Clinician Providers. By signing below, the employee acknowledges that they have:Watched the Behavioral Health Clinic Training video and reviewed the training slides as specified in the requirements provided by Carelon Behavioral Health of Connecticut.Reviewed all necessary documentation, including the "Attestation for Behavioral Health Clinician Groups and Solo Clinicians in Independent Practice" form.Understood and agreed to abide by all applicable laws, regulations, and enrollment agreements related to their role as a Behavioral Health ClinicianReviewed and understood the TCORS training video and reviewed the training slides as a specific in the requirements provided by TCORS Medicaid Attorney.
Title IX Responsible Employee FormTitle IX Responsible Employee Notice I understand that I am considered a Responsible Employee under the Latin Enrichment Organization Sexual Misconduct/Title IX polices, and that as a Responsible Employee, I am required to understand and adhere to the following requirements:Read and comply with the Clinic’s Title IX: Sexual Misconduct Policy, located in the SexualMisconduct section of LEO Clinic Employee Handbook.Report any concerns about sexual misconduct involving a Latin Enrichment Organization patient, partners, or staff member, to a Title IX Coordinator or Title IX Deputy within 24 hours of my becoming aware of the concern.A report to the Title IX Coordinator/Deputy is required even if the patient or employee requests confidentiality. Upon receiving a report, the Title IX Coordinator/Deputy will make every effort to maintain confidentiality to the extent possible. A report should be made even in situations where the Responsible Employee has not received a formal complaint, but has reason to believe that a LEO Clinic patient or employee may be impacted by sexual misconduct.If a patient reports an issue of possible sexual misconduct to an part time staff member, thePart-Time staff should:Inform the patient that the PT is a Responsible Employee who is required to report to a Title IXCoordinator.Advise the patient that there is confidential assistance available at the Clinic and from non-Clinic providers.Inform the patient that information and resources are available on LEO Clinic website under Sexual Misconduct.If there is any indication of immediate risk of harm to any individual, notify LEO Clinic PublicSafety and/or call 911. Contact a Title IX Coordinator/Deputy with any questions related to Title IX/Sexual Misconduct.
Direct Deposit Account Information

Routing NumberAccount Number
Bank Name
Direct Deposit Information 1. For a checking account, please bring a one of the following to your HR Orientation; a blank voided check from your bank, a print out from your on-line banking with the ACH routing number and account number, or a validation letter from your financial institution indicating the ACH routing number and account number. 2. For a savings account, please bring a one of the following to your HR Orientation; a statement from your bank indicating the ACH routing number and savings account number or a print out from your on-line account indicating the ACH routing number and savings account number. 3. A deposit form will not be accepted as proof of routing number and/or account number. I hereby authorize The Latin Enrichment Organization to initiate direct deposit(s) in the account(s) and financial institution(s) listed above. Should funds be erroneously deposited into my account(s), I authorize the University to debit my account for the appropriate adjustment(s). If the financial institution is not able to deposit the electronic transfer into my account, I understand that the Clinic assumes no responsibility for processing a supplemental payment until the non-accepted deposit is returned to the Clinic. I am aware that there will be a waiting period of 10 days or at least 2 pay periods for the direct deposit to take effect.
Voided Check or Bank Letter

N/A for Interns
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Clinical Privileges

INSTRUCTIONSApplicant: Check off the "Requested" box for each privilege requested. Applicants have the burden of producing information deemed adequate by the Clinic for a proper evaluation of current competence, current clinical activity, and other qualifications and for resolving any doubts related to qualifications for requested privileges. Director: Check the appropriate box for recommendation on the last page of this form. If recommended with conditions or not recommended, provide condition or explanation on the last page of this form.
OTHER REQUIREMENTS

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.

Primary Care Outpatient Providers

Rows	Requested	Approved Request	Decline Request	N/A
Management of Routine Pediatric Care 12 yr under
Management of Routine Adolescent Care
Management of Routine Adult Care
Management of Routine Prenatal Care
Management of Routine Geriatric Care
Supervision of Residents & Students
Cardiopulmonary resuscitation (BLS)
Initial evaluation of musculoskeletal problems
Suturing of simple lacerations (one layer)
Use of local anesthics for wound repair
Superficial Nerve Block
Debridement, skin or subcutaneous, tissue
Treatment uncomplicated dermatological conditions
Needle aspiration of subcutaneous lesion
Treatment of planter warts
Dressing/Debridement, burn
Lacerations, infected
Suturing of simple 2 layer lacerations
Special competency based on appropriate experience, training, credentials, or documentation

I am requesting the approve privileges: Signature

Behavioral Health Providers

Rows	Requested	Approved Request	Decline Request	N/A
Initial Psychiatric Evaluation-Intake
Initial Substance Abuse Evaluation
Treatment Planning
Psychotherapy (Individual)
Psychotherapy (Family)
Psychotherapy (Group)
Treatment of Dual Diagnoses
Couples Therapy/Family Therapy
Psychopharmacology (DR or APRN Only)
Genetic Psychiatry/Counseling
Cognitive Behavior Therapy
Behavioral Health Consultation
Provide Service for Pediatric Patients (newborn to 1 year)
Provide Service for Adolescents (13-19 years of age)
Provide Service for Pediatric Patients (1 year thru 12 years)
Behavioral In-Home Therapy
Psychiatric Medication Management (DR or APRN Only) P
Autism Treatment
Suicide and Homicide Counseling
Eating Disorder Treatment

I am requesting the approve privileges:
Should be Empty:

LEO Clinic Employment Application

Emergency Contact

Policy Acknowledges Form

Clinical Privileges

OTHER REQUIREMENTS