EMPLOYMENT APPLICATION

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.

 Please read "Applicant Note” below.
 Complete all pages of this application.
 Incomplete or illegible applications may not be accepted.
 If more space is needed to complete any question, use comments Section:
 Application will be valid for 60 days.

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with our Home Care Agency. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to employment.

DISCLAIMER

Applicant understands that this is an Equal Opportunity Employer and committed to excellence through diversity. In order to ensure this application is acceptable, please print or type with the application being fully completed in order for it to be considered.

Please complete each section EVEN IF you decide to attach a resume.                                                 

  I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my eventual employment, I understand that any false or misleading information in my application or interview may result in my employment being terminated.

APPLICANT CERTIFICATION AND RELEASE: 

I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief.

I understand that any false information, omissions, or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations.

I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check.

I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between the Company and myself is terminable at-will, so that both the company and I remain free to choose to end our work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing.

My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.

 

THE DESIGNATED PROGRAM: PHYSICIANS  ACKNOWLEDGMENT OF EMPLOYEE’S RIGHTS AND DUTIES UNDER PENNSYLVANIA LAW 

If I am involved in a work-related injury, I should report the incident to my supervisor and seek treatment with a health care provider on the list posted by my employer.

 I understand and acknowledge the following rights and duties:

I have the duty to obtain treatment for work-related injuries and illnesses from one or more of the health care providers designated by my employer for 90 days from my first visit.

As long as I continue to treat with a provider designated by my employer during the 90-day period, I have the right to have expenses for all reasonable medical supplies and treatment related to the injury paid by my employer.

I have the right to switch from one health care provider on my employer’s list to another on that list during the 90-day period, and my employer will pay for this treatment.

If a provider designated by my employer refers me to a provider not designated by my employer, my employer must pay for the treatment.

I have the right to seek emergency medical treatment from any provider, but I understand that subsequent non-emergency care must be sought from a provider designated by my employer for the remainder of the 90-day period.

I have the right to seek medical treatment or consultation from a provider not designated by my employer at my own expense during the 90-day period.

After 90 days, I have the right to seek treatment from any health care provider, and my employer shall pay for all reasonable and necessary care.

After 90 days, I may treat with a health care provider not designated by my employer, but I understand that I must notify my employer within five days of my first visit. Prior to receiving this notification, my employer may not be responsible for payment for the services provided. After notification, my employer shall pay for all services found to be reasonable.

If a designated provider prescribes invasive surgery, I understand that I have the right to seek an additional opinion from any health care provider of my choice. If the additional opinion differs and provides a specific and detailed course of treatment, I am entitled to select between the treatment plans. If I select the alternative outlined by the additional opinion, a provider on my employer's designated list shall perform the treatment for 90 days from the date of my first visit to the provider of the additional opinion.

 THE DESIGNATED PHYSICIANS PROGRAM:ACKNOWLEDGMENT OF EMPLOYEE’S RIGHTS AND DUTIES UNDER PENNSYLVANIA (CONTINUED)

If my employer is not liable, I understand that I am responsible for making the full payment for services rendered.

I acknowledge that I have been informed of and understand these rights and duties and that I have reviewed the list of designated providers.

                          ANTI-FRAUD LEGISLATION

In accordance with the Anti-Fraud Legislation passed by the Commonwealth of Pennsylvania, insurance carriers are required to advise all policyholders and claimants of the following:

Any person who – knowingly and with intent to defraud any insurance company of other person-files an application for insurance or statement of claim containing any materially false information or conceals (for the purpose of misleading) information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.