HH APPLICATION PACKET

Employment Application
Personal Information
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
example@example.com
Birth Date*

MonthDayYear
Are You a U.S. Citizen?*

YesNo
Do You Own A Car?*

YesNo
Do You Have A Drivers License?*

YesNo
Do You Have Insurance Coverage on Your Car?*

YesNo
Distance Willing To Travel?*
What Languages Do You Speak?

Military Service
Have You Ever Served in the Military?*

YesNo
If Yes, What Branch?
From

MonthDayYear
To

MonthDayYear
Rank of Discharge
Type of Discharge
If Other Than Honorable, Please Explain.

Felony Background
Convicted Of A Felony?*

YesNo
If Yes, Please Explain

Skills/Qualifications
Skills*
List any relevant skills
Qualifications*
List any relevant certifications or qualifications

Employment History

Please provide past work history containing a continuous description of activities over the past 5 years
Current Employer*
Name of Current Employer or NONE if not Employed
Position*
Salary
Start Date*

MonthDayYear
Name of supervisor*

First NameLast Name
Phone Number*
Email
example@example.com
Previous Employer*
Name of Previous Employer
Position*
Start Date*

MonthDayYear
End Date*

MonthDayYear
Salary
Reason for Leaving?*
Name of supervisor*

First NameLast Name
Phone Number*
Previous Employer
Name of Previous Employer
Position
Start Date

MonthDayYear
End Date

MonthDayYear
Salary
Reason for Leaving?
Name of supervisor

First NameLast Name
Phone Number
Did you provide past work history containing a continuous description of activities over the past 5 years?*

YesNo
If no, please provide additional information on work history up the past 5 years *
Follow the following format: Employer Name, Position, Start Date (MM-DD-YYYY), End Date (MM-DD-YYYY), Reason for Leaving, Name and Phone Number of Supervisor. Write N/A if this question if not applicable
Please provide reasons for any gaps in your work history*
Sample answers could be: "I worked as an artist/freelancer between 2020-2022." Write "N/A" if this question is not applicable.

References

Each applicant must provide at least 3 individuals as personal references, one of whom shall have known the applicant for at least five (5) years. References cannot include family members
Reference 1*
Name of Reference
Relationship*
Years Acquainted*
Phone Number*
Email
example@example.com
Reference 2*
Name of Reference
Relationship*
Years Acquainted*
Phone Number*
Email
example@example.com
Reference 3*
Name of Reference
Relationship*
Years Acquainted*
Phone Number*
Email
example@example.com

Emergency Contact Form

Harmony Health emergency contact information
This information will only be used in case of an emergency.

Employee: First Name* Last Name*
Contact 1*
Name of Contact
Relationship*
Phone Number*
Email
example@example.com
Contact 2*
Name of Contact
Relationship*
Phone Number*
Email
example@example.com
Contact 3
Name of Reference
Relationship
Phone Number
Email
example@example.com

Document Uploads
Resume

Cancelof
CPR Certification

Cancelof
Driver's License

Cancelof
Social Security Card

Cancelof

Declination Influenza Vaccination
Harmony Health has recommended that I receive influenza vaccination in order to protect the members I serve.

I acknowledge that I am aware of the following facts:
- Influenza is a serious respiratory disease that kills an average of 36000 persons and hospitalizes more than 200000 persons in the United States each year.
- Influenza vaccination is recommended for me and all other direct support
  personals to prevent influenza disease and its complications including death.
- If I contract influenza, I will shed the virus for 24-48 hours before influenza symptoms appear. My shedding the virus can spread influenza infection to members I support.
- If I become infected with influenza, even when my symptoms are mild, I can spread severe illness to others.
- I understand that the strains of virus that can cause influenza infection change almost every year, which is why a different influenza vaccine is recommended each year.
- I cannot get the influenza disease from the influenza vaccine.
- The consequences of my refusing to be vaccinated could endanger my health and the health of those with whom I have contact, including the members I support, my coworkers, my family and my community.
Do you accept or decline the influenza (flu) vaccination?*

AcceptDecline
If I declined the influenza vaccination, I understand that I may change my mind at any time and accept influenza vaccination if the vaccine is available.

I have read and fully understand the information on this declination form.
Signature*
Name*

First NameLast Name
Date*

MonthDayYear
Date

Tuberculosis Skin Test
IName* have been informed that it is a company policy to submit a recent Tuberculosis testing result within 10 days of my application date. I understand that if these documents are not obtained, I will be removed from my assigned cases.
Signature*
Date*

MonthDayYear
Date

Background Check Consent Form
I voluntarily give Harmony Health the right to make a thorough background
investigation of my past employment and personal history, agree to cooperate in such investigation and release from all liability or responsibility, all persons, companies and/or entities supplying such information. I also authorize Harmony Health to conduct a drug screen, on me at any time.

Additionally, I agree that while I am employed by Harmony Health and for a period of 120 days after resigning from or being terminated by Harmony Health, I will neither solicit nor go to work with any competing healthcare staffing provider, current customer(s) of Harmony Health or any person or client having been seen by Harmony Health during the four months prior to my resignation or termination, unless approved in advance, in writing, by any officer of Harmony Health.
Signature*
Name*

First NameLast Name
Date*

MonthDayYear
Date

Responsibility Attestation
To:Name*

We appreciate you joining our personal support service team. Before you begin providing services, we wanted to spell out what you may expect from our company and in turn our expectations of you.

OUR RESPONSIBILITIES

Harmony Health, Inc is your employer of record when you provide in-home services to TennCare CHOICES Participants. It is our responsibility to explain your duties to you, provide supervision, pay your wages, and make sure that all required payroll related taxes (Federal Income taxes, FICA, Medicare, Workers' Compensation, Unemployment Compensation) are paid. We are also responsible for providing annual training, so you have the knowledge to perform your duties for CHOICES participants in their home.

It is the policy of the TennCare CHOICES Program that a criminal history background check is done for all people who provide direct care or have indirect contact with elderly or disabled people in their home. As an employer of in-home support workers, we are required to conduct a background check on each person we employ who will come in direct contact with a TennCare CHOICES participant.

YOUR DUTIES

As your employer, we expect the following from you:
1. Must pass a criminal background check.
2. Must receive positive references from the majority of individuals you’ve given us to contact.
3. Must have appropriate credentials, licensure, or certification (if required) and adequate training to provide services.
PERSONAL CARE VISITS

Intermittent visits of limited duration to provide hands-on assistance to an enrollee who, due to age and/or physical disability, needs help with activities of daily living such as bathing, dressing and personal hygiene, eating, toileting, transfers and ambulation; assistance with instrumental activities of daily living such as picking up medications or shopping for groceries, and meal preparation or household tasks such as making the bed, washing soiled linens or bed clothes, that are essential, although secondary, to the personal care tasks needed by the enrollee in order to continue living at home because there is no household member, relative, caregiver, or volunteer to meet the specified need.
Personal care does not include:
- Companion or sitter services, including safety monitoring and supervision;
- Care or assistance including meal preparation or household tasks for other residents of the same household;
- Yard work; or
- Care of non-service-related pets and animals.
IN HOME RESPITE
Services provided to individuals unable to care for themselves, furnished on a short-term basis because of the absence or need for relief of those persons normally providing the care. Services provided are the same as those outlined under personal care visits.

ATTENDANT CARE
The attendant care service involves hands-on assistance, safety monitoring and supervision of an enrollee who, due to age and/or physical disability, needs more extensive assistance than can be provided through intermittent personal care visits. This may include:
- assistance with activities of daily living such as bathing, dressing and personal hygiene, eating, toileting, transfers and ambulation;
- assistance with instrumental activities of daily living such as picking up medications or shopping for groceries, and meal preparation or household tasks such as making the bed, washing soiled linens or bedclothes, that are essential, although secondary to the personal care tasks needed by the enrollee in order to continue living at home; or
- continuous monitoring and supervision because there is no household Member, relative, caregiver, or volunteer to meet the specified need.
Attendant care does not include:
- Care or assistance including meal preparation or household tasks for other residents of the same household;
- Yard work; or
- Care of non-service-related pets and animals.
As a CHOICES service provider, we have promised our employees will foster respect, dignity, privacy, and confidentiality for people served by CHOICES. This includes allowing people to decide whether to be part of a program or activity. Additionally, we assure our employees will not improperly attempt to gain any money or goods from any enrollee or their family.

If you need clarification on any of these issues or if you are unable to comply with any requirements, please let your supervisor know.

Your signature below signifies that you have been advised of these expectations.
Signature*
Date*

MonthDayYear
Date

RULES OF CONDUCT

Addendum to Policies and Procedure Manual
To all Harmony Health employees:

All Harmony Health employees are to always conduct themselves in a professional manner while in the residence of a member receiving care. The following points are not meant to be all-inclusive, rather to serve as a basic guideline for expected Rules of Conduct. Please read all points carefully, and refer to the Employee Manual for additional guidance:

CALLING OUT ON A SHIFT
Calling out should be limited to EMERGENCY SITUATIONS ONLY and should be accompanied by a follow-up note from the doctor (if applicable). Calling out via text message is NOT ACCEPTABLE; all call-outs must be made by telephone. A Direct Support Professional (DSP) must provide at least 24-hour notice for a call-out request to enable Harmony Health to secure a replacement. Our priorities should be the members that we care for. If you are not there and we are unable to find a replacement, that patient suffers. Please keep this in mind and the professionalism and responsibilities required of you in the job. Excessive call-outs or misconduct will result in written warnings and ultimately termination. No show without prior notification will result in immediate termination.

Requested TIME OFF
All requests for time off should be submitted in writing with weekly paperwork. Requested time off should be submitted at least one month in advance.

Timesheet
In the event that you must submit a manual timesheet, your timesheet must be recorded by 5:00 a.m. on Monday morning. All timesheets and paperwork MUST be received in the Nashville office by 10:00 AM on Monday. If you are faxing, originals must follow.

Do not remove paperwork/timesheets from a member's home under any circumstances. If you need more paperwork, please contact our Hermitage office.

PLEASE be neat when filling out your timesheets. If we cannot read what you write, you will not be paid until we can clarify what you have turned in.

Random Drug Testing
Refusing a drug screen/test, either random or scheduled, requested at the discretion of Harmony Health, Inc. is grounds for immediate termination.

Dress Code
Proper dress code is required at all times. There are no exceptions to the guided persona in the Employee Manual (I.e. good personal hygiene).

Employee Conduct
Employees are NOT ALLOWED to handle medication in any way.

Employees are NOT ALLOWED to drive the member's vehicle.

Employees are NOT ALLOWED to take children or other family members into a member's home during a shift.

Under NO circumstances is sleeping at a member's residence acceptable.

Unless conducting homemaker services or running errands, or unless specifically requested by the member or member's family, the employee should remain in the same room of the residence as the member while providing care during the entire shift.

Personal matters need to be kept personal! DO NOT burden the member or their family with your personal or financial problems. Often, the member's health causes too much stress and strain on them already, and dumping your personal issues on them is overbearing and affects the member’s care and health. Violating this rule is grounds for being removed from the case and possibly terminated. We cannot stress this enough!

Clock-in/Out Procedures
Employees are REQUIRED to clock in/out using the The Electronic Visit Verification (EVV) system upon arrival at member's residence, upon a service change (Personal Care, Attendant Care, Homemaker, or In-Home Respite), and prior to departure. The system acts as verification that services are being performed within the members preferred schedule, approved location and may also be utilized by the provider for submission of claims.

To use the EVV system, employees check in using a GPS tablet device at the member’s home promptly on arrival. The employee may download the EVV application to their own Android or Apple smartphone at no charge, which can be used for checking in and out of a visit if the member’s tablet is not available. This confirms the identity of the member provider/staff worker as well as the arrival time and location. If neither of these options are available, the DSP can utilize the member’s LANDLINE phone to check in. At the end of the shift or assignment (and prior to leaving the member’s home), the provider/staff worker will check out using the tablet device or the same method in which the check in occurred, logging the departure time and completing a brief survey. This survey will only be available via the tablet method for checking out.

If a provider/staff worker fails to check in at the appropriate time, the EVV system will alert the Managed Care Organization (MCO) and steps will be taken to ensure the member receives the appropriate care at the appropriate time. Failure to follow these procedures in a timely manner
could result in nonpayment for services rendered for both Harmony Health and you the employee.

DSPs are the first line of sight into technology issues that may affect the tablets. Please be sure to communicate any issues with the tablet and/or other methods of check in/out with the Harmony Health EVV team. This includes if the tablet is not available, the tablet is unable to be turned on, the tablet is not receiving a signal, the tablet is broken, the DSP is unable to use the mobile application for check in/out or the member receiving care does not have a phone the caregiver can use to check them in/out. The EVV support staff will guide you on next steps to ensure appropriate steps are taken to inform the MCO of these issues and that the DSP time is accurately reflected.

If you are late to call in for a shift, DO NOT put on your timesheet that you were on time. Your sheets are reconciled (compared) to the EVV system call times each week for accuracy. If there are discrepancies, you will be contacted and verbally warned.

All schedule/time changes MUST be approved by a Supervisor PRIOR TO the shift, as those changes must be input into the EVV system prior to beginning a shift. NO EXCEPTIONS. Failure to follow this rule could result in non-payment for hours worked.

Money Management
If the employee handles money for the member (i.e., while running an errand), the Cash/Medication Verification Form (CMV) MUST BE filled out and signed by the member on every occasion. A duplicate copy of the receipts from any purchases is to be submitted with the CMV form and turned into our office along with weekly paperwork. If physical copies of the CMV Forms are needed in the home, please contact our office.

To provide the best possible care to our members, and to stand out from the other companies, we must be consistent and diligent in our actions everyday while in a member’s home. I trust that you will read these guidelines carefully and take them to heart. We appreciate what you do
and the extra care that you provide our members. You have all contributed to our growth and good reputation in our choices program. Let’s continue to exceed the expectations of our members and their families and keep the momentum going.

Resignation Policy
All employees are required to provide a minimum of two weeks' written notice prior to their last day of employment by submitting a formal resignation letter to their direct supervisor, outlining their intention to leave and specifying their last day of work, which will be two weeks from the date of the letter. Failure to provide adequate notice may result in the company withholding their last paycheck.

Please sign below your acknowledgement and acceptance of these rules of conduct and return his page only to our office.

Sincerely

Chidinma I. Iwueke
Director

I acknowledge and accept these rules of conduct and understand the necessity of following them while conducting business for efficient supports.
Signature*

COVID-19 Protocol 1: Employee Health Screening
Employee information:
Name*

First NameMiddle NameLast Name
Position
Date

MonthDayYear
Date
Health Screening:
1. Have You Experienced Any COVID-19 Symptoms in the Past 14 Days?*

YesNo
2. If Yes, Please Specify Symptoms:
3. Have You Been in Close Contact with Someone Diagnosed with COVID-19 in the Past 14days?*

YesNo
4. Have You Traveled Internationally or to Any High-risk Areas in the Past 14 Days?*

YesNo
Precautionary Measures:
- I understand the importance of reporting any COVID-19 symptoms or exposure to my supervisor immediately.
- I agree to follow all safety protocols and guidelines provided by Harmony Health.
Acknowledgement:

I acknowledge that I have read and understand the COVID-19 health screening protocol provided by Harmony Health. I agree to comply with all safety measures and procedures to ensure the health and safety of myself, my colleagues, and our clients.
Signature*
Date*

MonthDayYear
Date

COVID-19 Protocol 2: Client Interaction Guidelines
Client Interaction:
- All Harmony Health employees must wear appropriate personal protective equipment (PPE) during client visits, including masks, gloves, and gowns, as necessary.
- Employees must practice social distancing whenever possible during client interactions, maintaining a distance of at least 6 feet.
- Hand hygiene is essential. Employees must wash their hands frequently with soap and water for at least 20 seconds or use hand sanitizer with at least 60% alcohol.
- Employees must notify their supervisor immediately if they experience any symptoms of illness or come into close contact with someone diagnosed with COVID-19.
Cleaning and Disinfection:
- Employees must clean and disinfect all equipment and surfaces between client visits using EPA-approved disinfectants.
- High-touch surfaces, such as doorknobs, light switches, and countertops, should be cleaned and disinfected frequently throughout the day.
Client Communication:
- Employees should communicate openly and transparently with clients about COVID-19 safety measures and encourage their participation in maintaining a safe environment.
- Clients should be informed of any changes to Harmony Health's policies or procedures related to COVID-19.
Acknowledgement:

I acknowledge that I have read and understand the COVID-19 client interaction guidelinesprovided by Harmony Health. I agree to adhere to all safety protocols and procedures to protect the health and well-being of our clients and employees.
Signature*
Date*

MonthDayYear
Date

Harmony Health LLC

Client ID: 1784
DISCLOSURE AND AUTHORIZATION FORM

BACKGROUND INVESTIGATION QUESTIONNAIRE
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Social Security*
Do not include hypens
Phone Number*
Other Name(s), include year of name change in brackets*
(Used Within the Last 7YRS. E.g. Maiden, Other Married Names (i.e 2023)
Drivers License*
Name on Drivers License*

First NameMiddle NameLast Name
Previous Residential Address 1 (Previous 7 years)*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Years Resided*
Previous Residential Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Years Resided
Previous Residential Address 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Years Resided
Have You Been Convicted of Any Criminal Offense, Either Misdemeanor or Felony, Other Than Minor Traffic Violations in the Last 7 Years?*
Are You Currently Charged or Under Investigation for Any Violation of the Law Other Than Minor Traffic Violations?*

DISCLOSURE AND AUTHORIZATION FORM

IMPORTANT - PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

HARMONY HEALTH LLC may obtain information about you from a consumer reporting agency for Employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants as a tenant is an investigation into your education and/or employment history conducted by Fowlers' Profile Links, Inc., PO Box 291043, Nashville, TN, 37229, 1-866-887-7581 or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing HARMONY HEALTH LLC to obtain from any outside organization all manners of consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Company at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Fowlers' Profile Links, Inc., PO Box 291043, Nashville, TN, 37229, 1-866-887-7581 another outside organization acting on behalf of HARMONY HEALTH LLC , and/or HARMONY HEALTH LLC , itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

NOTICE: Fowlers’ Profile Links, Inc. requests your Date of Birth solely for the purpose of verifying certain records that may be produced in connection with Fowlers’ Profile Links, Inc. background investigation. It is the policy of this facility to provide equal opportunity to persons regardless of race, religion, age, gender, disability or any other classification in accordance with federal, state and local statutes, regulations and ordinances.

Para informacion en espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

A Summary of Your Rights According to the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free.

You are entitled to a free file disclosure if:

a person has taken adverse action against you because of information in your credit report;
you are the victim of identify theft and place a fraud alert in your file;
your file contains inaccurate information as a result of fraud;
you are on public assistance;
you are unemployed but expect to apply for employment within 60 days.

In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.ftc.gov/credit for additional information.

You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.ftc.gov/credit for an explanation of dispute procedures.

Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.ftc.gov/credit.

You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-567-8688.

You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

Identity theft victims and active duty military personnel have additional rights. For more information, visit www.ftc.gov/credit. States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. Federal enforcers are:

TYPE OF BUSINESS:	CONTACT:
Consumer reporting agencies, creditors and others not listed below	Federal Trade Commission: Consumer Response Center -FCRA Washington, DC 20580 1-877-382-4357
National banks, federal branches/agencies of foreign banks (word "National" or initials "N.A." appear in or after bank's name)	Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC 20219 800-613-6743
Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks)	Federal Reserve Board Division of Consumer & Community Affairs Washington, DC 20551 202-452-3693
Savings associations and federally chartered savings banks (word "Federal" or initials "F.S.B." appear in federal institution's name)	Office of Thrift Supervision Consumer Complaints Washington, DC 20552 800-842-6929
Federal credit unions (words "Federal Credit Union" appear in institution's name)	National Credit Union Administration 1775 Duke Street Alexandria, VA 22314 703-519-4600
State-chartered banks that are not members of the Federal Reserve System	Federal Deposit Insurance Corporation Consumer Response Center, 2345 Grand Avenue, Suite 100 Kansas City, Missouri 64108-2638 1-877-275-3342
Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission	Department of Transportation , Office of Financial Management Washington, DC 20590 202-366-1306
Activities subject to the Packers and Stockyards Act, 1921	Department of Agriculture Office of Deputy Administrator - GIPSA Washington, DC 20250 202-720-7051

Signature*
Date*

MonthDayYear
Date

HIPAA EMPLOYEE CONFIDENTIALITY AGREEMENT
THIS AGREEMENT entered into this Date* by and between HARMONY HEALTH LLC , known as the “Service Provider”, and First Name* Last Name*, known as the “Employee”, and known collectively as the “Parties”, set forth the terms and conditions under which information created or received by or on behalf of this Service Provider (known collectively as protected health information or “PHI”) may be used or disclosed under State law and the Health Insurance Portability and Accountability Act of 1996 and updated through HIPAA Omnibus Rule of 2013 and will also uphold regulations enacted there under (hereafter “HIPAA”).

THEREFORE, in consideration of the premises and the covenants and agreements contained herein, the Parties hereto, intending to be legally bound hereby, covenant and agree as follows:

1. Confidential Information. The Parties acknowledge that meaningful employment may or will necessitate disclosure of Confidential Information by this Service Provider to the Employee and use of Confidential Information by the Employee. The term “Confidential Information” includes, but is not limited to, PHI, any information about patients or other employees, any computer log-on codes or passwords, any patient records or billing information, any patient lists, any financial information about this Service Provider or its patients that is not public, any intellectual property rights of Practice, any proprietary information of Practice and any information that concerns this Service Provider’s contractual relationships, relates to this Service Provider’s competitive advantages, or is otherwise designated as confidential by this Service Provider.

2. Disclosure. Disclosure and use of Confidential Information includes oral communications as well as display or distribution of tangible physical documentation, in whole or in part, from any source or in any format (e.g., paper, digital, electronic, internet, social networks, magnetic or optical media, film, etc.). The Parties have entered into this Agreement to induce use and disclosure of Confidential Information and are relying on the covenants contained herein in making any such use or disclosure. This Service Provider, not the Employee, is the records owner under state law and the Employee has no right or ownership interest in any Confidential Information.

3. Applicable Law. Confidential Information will not be used or disclosed by the Employee in violation of applicable law, including but not limited to HIPAA Federal and State records owner statute; this Agreement; the Practice’s Notice of Privacy Practices, as amended; or other limitations as put in place by Practice from time to time. The intent of this Agreement is to ensure that the Employee will use and access only the minimum amount of Confidential Information necessary to perform the Employee’s duties and will not disclose Confidential Information outside this Service Provider unless expressly authorized in writing to do so by this Service Provider. All Confidential Information received (or which may be received in the future) by Employee will be held and treated by him or her as confidential and will not be disclosed in any manner whatsoever, in whole or in part, except as authorized by this Service Provider and will not be used other than in connection with the employment relationship.

4. Log-on Code and Password. The Employee understands that he or she will be assigned a log-on code or password by Practice, which may be changed as this Service Provider, in its sole discretion sees fit. The Employee will not change the log-on code or password without this Service Provider’s permission. Nor will the Employee leave Confidential Information unattended (e.g., so that it remains visible on computer screens after the Employee’s use). The Employee agrees that his or her log-on code or password is equivalent to a legally binding signature and will not be disclosed to or used by anyone other than the Employee. Nor will the Employee use or even attempt to learn another person’s log-on code or password. The Employee immediately will notify this Service Provider’s HIPAA Privacy Officer upon suspecting that his or her log-on code or password no longer is confidential. The Employee agrees that all computer systems are the exclusive property of Practice and will not be used by the Employee for any purpose unrelated to his or her employment. The Employee acknowledges that he or she has no right of privacy when using this Service Provider’s computer systems and that his or her computer use periodically will be monitored by this Service Provider to ensure compliance with this Agreement and applicable law.

5. Returning Confidential Information. Immediately upon request by this Service Provider, the Employee will return all Confidential Information to this Service Provider and will not retain any copies of any Confidential Information, except as otherwise expressly permitted in writing signed by this Service Provider. All Confidential Information, including copies thereof, will remain and be the exclusive property of this Service Provider, unless otherwise required by applicable law. The Employee specifically agrees that he or she will not and will not allow anyone working on their behalf or affiliated with the Employee in any way, use any or all of the Confidential Information for any purpose other than as expressly allowed by this Agreement. The Employee understands that violating the terms of this Agreement may, in this Healthcare Facility’s sole discretion result in disciplinary action including termination of employment and/or legal action to prevent or recover damages for breach. Breach reporting is imperative.

6. Breach. The Parties agree that any breach of any of the covenants or agreements set forth herein by the Employee will result in irreparable injury to this Service Provider for which money damages are inadequate; therefore, in the event of a breach or an anticipatory breach, Practice will be entitled (in addition to any other rights and remedies which it may have at law or in equity, including money damages) to have an injunction without bond issued enjoining and restraining the Employee and/or any other person involved from breaching this Agreement.

7. Binding Arrangement. This Agreement shall be binding upon and endure to the benefit of all Parties hereto and to each of their successors, assigns, officers, agents, employees, shareholders and directors. This Agreement commences on the date set forth above and the terms of this Agreement shall survive any termination, cancellation, expiration or other conclusion of this Agreement unless the Parties otherwise expressly agree in writing.

8. Governing Law. The Parties agree that the interpretation, legal effect and enforcement of this Agreement shall be governed by the laws in the State of Tennessee and by execution hereof, each party agrees to the jurisdiction of the courts of the State. The Parties agree that any suit arising out of or relation to this Agreement shall be brought in the county where this Service Provider’s principal place of business is located.

9. Severability. If any provision under this Agreement shall be held invalid or unenforceable for any reason, the remaining provisions and statements shall continue to be valid and enforceable.

IN WITNESS WHEREOF, and intending to be legally bound, the Parties hereto have executed this Agreement on the date first above written, when signing below and after training on HIPAA Law with full understanding this agreement shall stand.
EMPLOYEE DOCUMENTATION OF HIPAA PRIVACY TRAINING
The Health Insurance Portability Act of 1996 (HIPAA) requires our privacy officer to train employees on our health information privacy policies and procedures to the HIPAA Omnibus Standards of 2013 which also includes HI-TECH and Protected Health Information (PHI), Electronic Protected Health Information (ePHI) and Electronic Health Records (EHR). All employees with treatment, payment or healthcare operations responsibilities, which allow access to protected health information, are trained with updates periodically as State and Federal mandates require. HIPAA also requires that we keep this documentation (that the training was completed) for six years after the training.

I, the undersigned, do hereby certify that I have received, read, understood and agree to abide by this Healthcare Facilities HIPAA Policies and Operating Procedures.
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