• Employment Application

    Employment Application

  • Personal Information

  • Format: (000) 000-0000.
  • Are You a U.S. Citizen?*
  • Do You Own A Car?*
  • Do You Have A Drivers License?*
  • Do You Have Insurance Coverage on Your Car?*

  • Military Service

  • Have You Ever Served in the Military?*
  • From
     - -
  • To
     - -

  • Employment Position

  • Available Start Date*
     - -
  • If Caregiver, Do You Have Prior Work Experience in Personal Support Services?*
  • What Shifts Are You Available?*
    Rows
  • Are You Open to Working in a Smoking Home?*
  • Are You Open to Working in a Home with Dogs?*
  • Are You Open to Working in a Home with Cats?*

  • Felony Background

  • Convicted Of A Felony?*

  • Skills/Qualifications

  • Education

  • Graduated?*
  • I Have My GED
  • Graduated?
  • Graduated?
  • Graduated?

  • 5-YR Employment History

    Please provide a CONTINUOUS 5-YEAR WORK HISTORY WITH NO GAPS. If you’ve had more than three jobs during this period, use the additional information section. For any gaps, explain them in the “Reason for Gaps in Work History” section (e.g., school, self-employed, unemployed, etc.)
  • Start Date*
     - -
  • Format: (000) 000-0000.
  • Start Date*
     - -
  • End Date*
     - -
  • Format: (000) 000-0000.
  • Start Date
     - -
  • End Date
     - -
  • Format: (000) 000-0000.
  • Did you provide past work history containing a continuous description of activities over the past 5 years?*

  • References (NO FAMILY MEMBERS)

    Each applicant must provide at least three personal references (NO FAMILY MEMBERS). At least one reference must have known the applicant for five (5) years or more.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact Form

    Harmony Health emergency contact information

  • This information will only be used in case of an emergency.

    Employee:   *   *   

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

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  • 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?*

  • 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.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Tuberculosis Skin Test

  • I* 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.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Responsibility Attestation

  • To:*


    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.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • RULES OF CONDUCT

    Addendum to Policies and Procedure Manual

  • CALLING OUT ON A SHIFTCALLING OUT ON A SHIFTTo 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 48-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 maintain the professionalism, reliability, and responsibilities required of you in this position.

    Disciplinary Policy & Termination
    Repeated call-outs, attendance issues, or misconduct may result in progressive disciplinary action, including a verbal warning, written warning, final written warning, and ultimately termination if the issue continues.

    Serious misconduct may result in immediate termination, at the Company's discretion, without following the normal progressive disciplinary process. Serious misconduct includes, but is not limited to: client abandonment; abuse, neglect, or exploitation; fraud or falsification of records, timekeeping, or EVV documentation; theft; serious safety violations; threats, violence, or intentional harm to others; unauthorized possession, use, distribution, or sale of prescription medications or illegal drugs; criminal or illegal activity, whether occurring on or off duty, that may reasonably affect client safety, an employee’s ability or suitability to perform their job, or Harmony Health’s operations, compliance obligations, or reputation; or other conduct that places a client, employee, or member of the public at significant risk.

    A no-call/no-show without prior notification may result in immediate termination.

    Harmony Health reserves the right to determine the appropriate level of disciplinary action based on the nature, severity, frequency, and circumstances of the conduct. The Company is not required to follow each step of progressive discipline before termination when the circumstances warrant more immediate action.

    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 inside the 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.

    At no time may an employee clock in through the Electronic Visit Verification (EVV) system without actually reporting to the member and providing the authorized services. Clocking in within the approved EVV distance of a member's residence and then leaving, or otherwise remaining clocked in while not providing services to the member for the recorded duration of the shift, is considered falsification of timekeeping records and may be considered fraudulent activity. Such conduct is considered serious misconduct and may result in immediate termination.

    Employees are required to accurately clock in and clock out at the beginning and end of each visit and to remain with and provide authorized services to the member during the time recorded as worked, except for authorized activities performed on the member's behalf or other circumstances permitted by the member's service plan and Harmony Health policy.

    If an employee fails to check in or out at the appropriate time or otherwise fails to follow required EVV procedures, the EVV system may alert the Managed Care Organization (MCO), and additional steps may be required to verify that the member received the appropriate care at the appropriate time. Failure to follow EVV procedures accurately and in a timely manner may result in the visit being considered noncompliant or denied for reimbursement and may result in disciplinary action.

    Employees must never knowingly submit, create, or allow an EVV record to reflect services or hours that were not actually provided. Intentional falsification of EVV records, including clocking in without providing services, leaving a member while remaining clocked in, or knowingly recording hours not worked, constitutes serious misconduct and may result in immediate termination without following the normal progressive disciplinary process.

    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 Harmony Health.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • HARMONY HEALTH LLC

    MEMBER NON-SOLICITATION, NON-CIRCUMVENTION, CONFIDENTIALITY & BUSINESS PROTECTION AGREEMENT

  • This Member Non-Solicitation, Non-Circumvention, Confidentiality & Business Protection Agreement (“Agreement”) is entered into between Harmony Health LLC (“Harmony Health” or “Company”) and:

    Caregiver/Employee Name:    *   *   
    Effective Date:    Pick a Date*   

    This Agreement is a condition of employment or continued employment with Harmony Health, subject to applicable law.

    1. PURPOSE OF AGREEMENT

    Harmony Health invests substantial time, resources, administrative support, recruiting costs, credentialing, training, scheduling, compliance oversight, payer relationships, member coordination, and other resources to obtain, develop, service, and maintain relationships with members receiving services through Harmony Health.
    Through employment with Harmony Health, a Caregiver may be introduced to Harmony Health members and their families and may develop close relationships with those individuals solely because Harmony Health assigned the Caregiver to provide services to them.

    This Agreement is intended to protect Harmony Health's legitimate business relationships and goodwill while not preventing the Caregiver from working in the caregiving profession or accepting employment with another employer.

    2. MEMBER RELATIONSHIPS BELONG TO HARMONY HEALTH

    The Caregiver acknowledges that members assigned to the Caregiver are clients/members of Harmony Health and were introduced to the Caregiver through the Caregiver's employment or assignment with Harmony Health.

    The Caregiver agrees that the Caregiver will not use a relationship, access, information, goodwill, or opportunity obtained through Harmony Health to divert, solicit, or appropriate a Harmony Health member for the Caregiver's own benefit or for the benefit of another person or organization.

    3. MEMBER NON-SOLICITATION

    During employment with Harmony Health and for twelve (12) months following the end of the Caregiver's employment or last assignment with a particular Harmony Health member, whichever is later, the Caregiver shall not, directly or indirectly:

    1. solicit, encourage, persuade, induce, or attempt to persuade a Harmony Health member to terminate, reduce, transfer, discontinue, or redirect services from Harmony Health;
    2. encourage or assist a Harmony Health member to transfer services to another home care agency, provider, caregiver, staffing company, or other service provider for the purpose of continuing substantially similar services outside Harmony Health;
    3. solicit or encourage a Harmony Health member to hire or retain the Caregiver privately or independently;
    4. offer or agree to provide private-pay, cash-pay, Medicaid-funded, insurance-funded, or other compensated caregiving services directly to a Harmony Health member outside Harmony Health;
    5. direct a Harmony Health member to another agency, business, caregiver, relative, associate, or entity with which the Caregiver is affiliated for the purpose of circumventing Harmony Health;
    6. assist another individual or business in soliciting or obtaining a Harmony Health member; or
    7. use the Caregiver's relationship with a Harmony Health member, developed through Harmony Health, to divert the member's business or services away from Harmony Health.


    For purposes of this section, “Harmony Health Member” means a member to whom the Caregiver was assigned, provided services, met through Harmony Health, received information about through Harmony Health, or had material contact with because of the Caregiver's employment with Harmony Health during the twelve (12) months preceding termination of employment.

    4. NO PRIVATE ARRANGEMENTS WITH MEMBERS

    A Caregiver may not enter into any private employment, side arrangement, payment arrangement, independent caregiving arrangement, or other compensated service relationship with a Harmony Health member while employed by Harmony Health.
    This prohibition applies regardless of:

    • whether the member or family initiated the conversation;
    • whether the member offers to pay the Caregiver more than Harmony Health;
    • whether payment would be made in cash;
    • whether the Caregiver intends to work independently;
    • whether the Caregiver intends to work through another agency or company;
    • whether the Caregiver forms a new business;
    • whether the member states that he or she intends to leave Harmony Health; or
    • whether the Caregiver believes the arrangement would be more convenient for the member.


    If a member or member representative proposes such an arrangement, the Caregiver must decline and promptly notify Harmony Health management.

    5. MEMBER CHOICE

    Nothing in this Agreement is intended to interfere with a member's legal right to choose, change, or terminate his or her healthcare or service provider.

    A member remains free to discontinue Harmony Health services or select another qualified provider in accordance with applicable law and payer requirements.

    This Agreement restricts the Caregiver's conduct—not the member's freedom of choice.

    Accordingly, a member's independent decision to leave Harmony Health does not authorize the Caregiver to solicit, induce, facilitate, coordinate, or otherwise participate in moving the member away from Harmony Health in violation of this Agreement.

    6. NON-CIRCUMVENTION

    The Caregiver shall not accomplish indirectly what this Agreement prohibits directly.
    Prohibited circumvention includes, without limitation:

    • having another person approach a Harmony Health member on the Caregiver's behalf;
    • referring a member to an agency at which the Caregiver intends to work;
    • establishing or using another company to service the member;
    • having a friend, relative, associate, or business partner contract with the member;
    • asking a member to contact the Caregiver after the Caregiver leaves Harmony Health;
    • providing personal contact information for the purpose of arranging services outside Harmony Health;
    • encouraging a member to request the Caregiver through another provider;
    • coordinating a member's transfer to another agency with the expectation that the Caregiver will continue providing the member's care; or
    • otherwise arranging a transaction designed to avoid the restrictions contained in this Agreement.


    7. NO PRE-TERMINATION DIVERSION

    While employed by Harmony Health, the Caregiver shall not prepare to divert a Harmony Health member away from the Company.

    The Caregiver shall not discuss with a member or member representative plans to continue the caregiving relationship outside Harmony Health following the Caregiver's resignation, termination, transfer, or removal from the member's case.

    This restriction applies even if the proposed outside arrangement would begin only after the Caregiver's employment with Harmony Health ends.

    8. CONFIDENTIAL MEMBER AND BUSINESS INFORMATION

    During employment, the Caregiver may receive confidential information, including but not limited to:

    • member names and contact information;
    • member schedules;
    • service authorizations;
    • care plans;
    • payer information;
    • member preferences;
    • family and representative information;
    • caregiver assignments;
    • employee information;
    • rates and reimbursement information;
    • business procedures;
    • referral information;
    • internal records; and
    • other non-public Harmony Health information.


    The Caregiver shall not copy, retain, disclose, transmit, download, photograph, forward, or use such information except as necessary to perform authorized duties for Harmony Health.

    Confidential information may not be used to solicit members, caregivers, employees, referral sources, or business relationships for the Caregiver or another person or entity.

    Nothing in this Agreement prohibits disclosures protected or required by applicable law.

    9. EMPLOYEE NON-SOLICITATION

    During employment and for twelve (12) months following termination of employment, the Caregiver shall not directly solicit a Harmony Health employee or caregiver with whom the Caregiver materially worked or became acquainted through Harmony Health to leave Harmony Health for the purpose of joining the Caregiver, another agency, or another competing business.

    This provision does not prohibit general job advertisements or hiring an individual who independently responds to a general solicitation not directed at Harmony Health personnel.

    10. REPORTING MEMBER SOLICITATION

    If a Harmony Health member or member representative asks the Caregiver to:

    • work privately for the member;
    • leave Harmony Health and continue providing care;
    • move with the member to another agency;
    • accept payment directly from the member or family; or
    • otherwise provide services outside Harmony Health,


    the Caregiver must immediately inform Harmony Health management and must not negotiate, encourage, facilitate, or accept the proposed arrangement.

    Reporting such a request does not penalize the Caregiver or the member. It allows Harmony Health to address the situation appropriately and in accordance with applicable program requirements.

    11. NO GENERAL PROHIBITION ON CAREGIVING EMPLOYMENT

    This Agreement does not prohibit the Caregiver from working for another home care agency, healthcare provider, staffing company, or other employer after leaving Harmony Health.

    It also does not prohibit the Caregiver from operating an independent caregiving business where otherwise permitted by law.

    The Caregiver is prohibited only from improperly soliciting, diverting, or circumventing Harmony Health's protected member and workforce relationships as described in this Agreement.

    12. BREACH AND REMEDIES

    The Caregiver acknowledges that violation of this Agreement may cause substantial and difficult-to-measure harm to Harmony Health, including loss of member relationships, revenue, goodwill, administrative investment, and business opportunities.

    To the fullest extent permitted by Tennessee law, Harmony Health may pursue available legal or equitable remedies for an actual or threatened violation of this Agreement, including:

    1. temporary, preliminary, or permanent injunctive relief where legally appropriate;
    2. recovery of actual damages caused by the breach;
    3. recovery of profits or other amounts wrongfully obtained as a result of the breach where permitted by law;
    4. other damages or equitable relief available under applicable law; and
    5. reasonable attorneys' fees and costs to the extent recoverable under this Agreement or applicable law.


    The remedies available under this Agreement are cumulative to the extent permitted by law.

    13. NO AUTOMATIC PENALTY

    The parties acknowledge that damages resulting from member diversion may vary substantially depending upon the circumstances. Accordingly, this Agreement does not impose an automatic monetary penalty merely because a member terminates Harmony Health services.

    Harmony Health must establish a breach by the Caregiver and may seek the remedies legally available for that breach.

    14. RETURN OF COMPANY AND MEMBER INFORMATION

    Upon termination of employment or at Harmony Health's request, the Caregiver shall immediately return or permanently delete, as directed and permitted by law, all Harmony Health property and confidential information in the Caregiver's possession or control.

    The Caregiver shall not retain member lists, schedules, contact information, screenshots, photographs, care plans, authorization information, or other Harmony Health records.

    15. REASONABLENESS OF RESTRICTIONS

    The Caregiver acknowledges that:

    1. this Agreement does not prevent the Caregiver from earning a living as a caregiver;
    2. the Caregiver remains free to work for competing agencies or other employers;
    3. the restrictions are directed specifically toward relationships obtained through Harmony Health;
    4. the restrictions are intended to protect Harmony Health's legitimate business interests rather than prevent lawful competition; and
    5. the Caregiver has been given an opportunity to review this Agreement before signing.


    16. SEVERABILITY AND MODIFICATION

    If any provision of this Agreement is determined to be invalid, unlawful, or unenforceable, the remaining provisions shall remain effective to the fullest extent permitted by law.

    To the extent permitted under Tennessee law, a court may modify or limit an otherwise enforceable provision so that it is reasonable and enforceable rather than invalidating the Agreement in its entirety.

    17. GOVERNING LAW

    This Agreement shall be governed by and interpreted under the laws of the State of Tennessee, without regard to conflict-of-law principles.

    18. SURVIVAL

    The confidentiality, non-solicitation, non-circumvention, remedies, and other provisions that by their nature are intended to continue following termination shall survive the end of the Caregiver's employment.

    19. ENTIRE AGREEMENT

    This Agreement constitutes the agreement between Harmony Health and the Caregiver concerning the subjects addressed herein and supplements any confidentiality, HIPAA, employment, handbook, EVV, member protection, or other policies applicable to the Caregiver.

    If a conflict exists between this Agreement and applicable federal or Tennessee law, applicable law controls.

    20. ACKNOWLEDGMENT

    By signing below, the Caregiver acknowledges that the Caregiver:

    • has read this Agreement;
    • understands its requirements;
    • has had an opportunity to ask questions before signing;
    • understands that Harmony Health members remain free to select their providers;
    • understands that the Caregiver may work for another agency after leaving Harmony Health; and
    • agrees not to use relationships obtained through Harmony Health to solicit, divert, or take Harmony Health members or employees.


    CAREGIVER/EMPLOYEE ATTESTATION

    Please sign below your acknowledgement and acceptance of this Member Non-Solicitation, Non-Circumvention, Confidentiality & Business Protection Agreement.


    Sincerely

    Chidinma I. Iwueke

    Director


    I acknowledge and accept this Member Non-Solicitation, Non-Circumvention, Confidentiality & Business Protection Agreement and understand the necessity of following them while conducting business for Harmony Health.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • COVID-19 Protocol 1: Employee Health Screening

  • Employee information:

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Health Screening:

  • 1. Have You Experienced Any COVID-19 Symptoms in the Past 14 Days?*
  • 3. Have You Been in Close Contact with Someone Diagnosed with COVID-19 in the Past 14days?*
  • 4. Have You Traveled Internationally or to Any High-risk Areas in the Past 14 Days?*

  • 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.

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  • 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.

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  • Harmony Health LLC

    Client ID: 1784

  • DISCLOSURE AND AUTHORIZATION FORM

    BACKGROUND INVESTIGATION QUESTIONNAIRE
  • Format: (000) 000-0000.
  • Drivers License*

  • 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
  • Date*
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  • HIPAA EMPLOYEE CONFIDENTIALITY AGREEMENT

  • THIS AGREEMENT entered into this    Pick a Date*   by and between HARMONY HEALTH LLC , known as the “Service Provider”, and    *   *, 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.

  • Date*
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  • Send Application

  • By clicking the submit button below, I certify that all of the information provided by me on this application is true and complete, and I understand that if any false information, ommissions, or misrepresentations are discovered, my application may be rejected and, if I am employed by one of our affiliates, my employement may be terminated at any time.  

    In consideration of my employment, I agree to conform to the hired company's rules and regulations, and I agree that my employment and compenstation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option.  

    I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company.  

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