I hereby authorize A-PLUS HOME HEALTH AGENCY to fully investigate my record and work qualifications and verify licensure/certification before or
during my employment, and to facilitate such investigation. All employment is contingent upon successful completion of all background checks as well as
physical examination and/or drug/alcohol screen. I so hereby authorize any persons having knowledge thereof to give such information to A-Plus
Home Health Agency upon request.
I certify that all statements made by me on this application for employment and accompanying resume are true and correct. I acknowledge that
misrepresentation, falsification or omission of facts may be grounds for rejection of my application; or if discovered after I am employed, such
misrepresentation, falsification or omission may result in termination of my employment.
I understand that if employed by the A-PLUS HOME HEALTH AGENCY, such employment is not for any definite period but is at will and may be
terminated by either party at any period of time and without prior notice.
I understand that any offer of employment is conditioned on my ability to establish eligibility under the Immigration Reform and Control Act of 1986.
I certify that I have read the job description for the position for which I have applied.

I hereby acknowledge that in the course of my employment, A-PLUS HOME HEALTH AGENCY will make available to me confidential data and information. Such electronic verbal and/or written information may consist of, but is not limited to:
patient health information; OASIS assessment information; lists of the names and addresses of patients/customers/employees; patients’ family histories; information relating to the organization’s financial and/or contractual relations with customers; referral sources; administrative manuals; computer generated listings and documents; telephone conversations; directives and policies relating to the internal operations of the organization; and various documents containing information relating to the organization’s recruiting, training, operating and soliciting functions. I understand that access to such information is only being made available to me in order that I may perform the duties for which I have been employed I specifically agree that:
1. During the course of my employment I will use such information only in connection with my employment and will not
disclose the same to any other person or the general public, except those individuals who are directed to communicate such
information at the appropriate time.
2. I will not copy and/or remove any such materials from the organization’s premises except as needed to perform the duties
for which I am employed.
3. I will ensure the security of such information throughout the day at the close of each day, and in preparation for transport.
4. Following my employment with the organization, I will immediately return to the organization all such materials and all
other agency property in my possession.
5. Following my employment with the organization, I will not directly or indirectly:
a. Disclose, solicit, use, or permit any other person to have access to the organization’s materials;
b. Cause any other individual to breach their confidentiality with the organization or solicit any employee to
leave the organization’s employ.
c. Solicit or induce any client of the organization to terminate the relationships the client has with the
organization.
6. I understand that any breach of confidentiality as stated herein will entitle the organization to injunctive relief, in addition
to disciplinary action, up to and including dismissal.
7. I will abide by the provisions of the “Confidentiality of Information” employment policy.

If you check Item Number 4., enter one of these: