Primary Care Solutions Application for Employment

PLEASE SCROLL DOWN TO COMPLETE THE APPLICATION

Federal and/or state law prohibits discrimination because of age, sex, color, creed, race national origin, religion, marital status, veteran or disability. Please refer to appropriate code list where coed entries are required. Please answer all questions on this application as completely as possible so we can evaluate it properly. This application may be accompanied by a resume.

Are you a citizen if If "No" What is your visa category status? Only U.S. Citizen Aliens who have legal right to work the United States? and remain permanently in the U.S. or Aliens who qualify as "intending citizens under the immigrating reform and control act of 1986 are eligible forYesNo Alien registration employment. number

I hereby give Primary Care Solutions permission to contact any employers listed on the previous page before giving any relevant information.

Primary Care Solutions of Ohio, Inc.

I hereby certify that to the best of my knowledge, the information that I have given in this application is accurate and complete. I understand that incorrect or misleading information may result in termination of this application and discharge from PCS employment, if employed. I have given PCS permission to verify all information I have provided about my education, past employment and activities. I authorize schools, past and current employers (that I approved in the employment section) to release any relevant information. If employed by PCS I will sign a Disclosure Agreement, in which I agree to protect PCS, the entire right, title and interest in certain ideas, inventions and other proprietary/confidential property developed and/or with PCS, time, money, materials and personnel while in PCS employment. (I understand that I may obtain now or at any time before my employment based upon request a blank copy of this agreement I agree to submit proof of eligibility to work ill the U.S. In consideration for employment, I agree that at any time my employment and compensation can be terminated, with or without cause, by PCS or myself with or without notice.

If hired, your signature attests that the medical record entries you will make accurately reflects your professional signature. Additionally, you understand that any falsification, omission, or concealment of material fact may subject you Lo administrative, civil, or criminal liability as it pertains to the services and documentation provided.

CRIMINAL HISTORY BACKGROUND CHECK

This authorization and consent for release of personal information acknowledges that PCSOH (hereafter referred to as "Company") and/or its agent, Secure Search, may now, or at any time I am assigned to, volunteer with, or am employed by this Company, conduct investigations into whether the records are of a public, private, or confidential nature. These investigations might include, but are not limited to, searches of educational institutions attended; previous employment, including work history; criminal history information on file in local, state, or federal agencies; and motor vehicle records.

I understand that these searches will be used to determine work assignment or employment eligibility under the Company's employment or volunteer policies. Therefore, I authorize and consent to the full release of records (either orally or in writing) to the authorized representatives of the Company. In addition, I release and discharge the Company, its agent, and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs, expenses, or any other charge or complaint filed with any agency arising from retrieving and reporting this information. I understand that according to the Federal Fair Credit Reporting Act, I am entitled to know whether employment was denied based upon the information obtained and to receive, upon a written request, a disclosure of the background report. After reading this document, I fully understand its contents and authorize the background verification.

CRIMINAL HISTORY BACKGROUND CHECK

I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS AUTHORIZATION IS TRUE, CORRECT, AND COMPLETE. I UNDERSTAND THAT IF ANY INFORMATION PROVES TO BE INCORRECT OR INCOMPLETE, GROUNDS FOR THE CANCELING OF ANY AND ALL OFFERS OF EMPLOYMENT OR VOLUNTEER POSITIONS WILL EXIST AND MAY BE USED AT THE DISCRETION OF THE EMPLOYER.

Primary Care Solutions of Ohio, Inc.

Background Check Process

Please follow the steps below to initiate and complete this process:

1. Applicant Registration:

Visit the registration portal at https://register.fastfingerprints.com/account-entry. Click on the "I HAVE A CODE" button.

Enter the BFBI code: 1YL07NCM (Please note that the O is the letter 0

2. Code Entry and Verification:

After entering the Access Code, confirm that the company identified is accurate. Select a convenient fingerprinting location. Provide your personally identifiable information as required. BCI/FBI Reason: Please enter code 2151.86 - Out of Home Child Care, Foster Parents, Adopt

Attend your scheduled fingerprinting appointment. Once your appointment is completed, the automated system will handle the subsequent steps to ensure efficient processing and seamless communication

Please ensure that this process is completed as soon as possible to facilitate your onboarding. If you have any questions or encounter any issues during the registration process, do not hesitate to

Note: You are welcome to scan the QR code on the next page (or follow the link below directly as an option to register for your Background Check. This step is required to be completed prior to PCS OH Orientation.

https://register.fastfingerprints.com/account-entry

Please send your Background Check Receipt & date of completion to the Office Manager, Lonna Floyd at LFloyd@pcs-oh.prg

Primary Care Solutions of Ohio, Inc.

AT WILL EMPLOYMENT CLAUSE: Employment contract provision indicting that employer or employee may terminate the employment relationship at any time with or without cause.

In consideration of employer entering into this agreement, employee agrees to conform to the policies and rules of employer in effect from time to time. Each party to this agreement also agrees that employee's employment and compensation can be terminated with or without cause, and without prior notice, at any time options of either employee or employer.

Primary Care Solutions of Ohio, Inc.

Assurance of Confidentiality & Federal Privacy Regulations

 

Confidentiality information includes (but is not limited to) photographs, videotapes, audiotapes, client records, reimbursement records; information stored in automated files, and clinical staff member client files.

I am aware that violation of this agreement could result in disciplinary actions at Primary Care Solutions of Ohio Inc and is a violation of Federal and Ohio laws that could result in civil penalties.

Primary Care Solutions of Ohio, Inc.

Confidentiality and Non-Disclosure Agreement

In consideration of employment of the undersigned (Employee) by Primary Care Solutions of Ohio (or any successor thereto), and in consideration of the wages and salary to be Paid. Employee agrees to the following:

1. Statement of Confidentiality Employee hereby attests that in his/her role with Primary Care Solutions, understand and accepts that they have access to the confidential information, but not limited to, client names, addresses and personal data, billing records, accounts, wages financials, and trust funds. Employee further understands that it is a violation of federal and state law to reveal confidential information, and subject to legal action for violation of applicable laws. Employee I also understand that it is against company Policy to reveal confidential information of any type to anymore not privileged to receive such information. Employee pledges absolutely to maintain, during and beyond employment with Primary Care Solutions, the confidentiality and security of this information as well as any of Primary Care Solutions proprietary information.

2. Statement of Non-Disclosure

Employee acknowledges that not to disclose of confidential information to Anyone other than persons authorized by Primary Care Solutions. Employee agrees to safeguard this confidential

a. to any other than Primary Care Solutions and officers or other persons, including employees authorizes by Primary Care Solutions, or use or otherwise exploit Employees will not directly or indirectly disclose for the Employee's own Benefit or for the benefit of anyone other than Primary Care Solutions, and Confidential information whether Such material is developed before or after the date of this Agreement or employee's employment with Primary Care Solutions.

b. Employees shall use his or her best efforts to cause all persons or entities to whom any Confidential Information shall be disclosed by him or her hereunder to observe the terms and conditions set forth herein as though each such person or entity were bound hereby. 12 I Page "Lifting as We Climb"

 

C. Employee shall have no obligation hereunder to keep confidential and Confidential Information if and to the extent disclosure of any such information is specifically required by law or if the information has been released to the public by Primary Care Solutions, provided, however, that in the Event discloser is required by applicable law. Employee shall Provide Primary Care Solutions with prompt notice to Such requirement, prior to making any disclosure, so that Primary Care Solutions may seek appropriate protective

3. Information, data and Materials constituting Confidential Information Confidential information includes, but is not limited to, such items,

a. any patent, patent application, copyright, trademark, trade name, service mark, service names," know-how" or trade secrets.

b. individuals we serve and information relating to any such individual or any party

c. customer lists and information relating to any client of Life Enhancement Services or any part-/related.

d. company records, operational methods and company policies and procedures, including manual and forms.

e. marketing data, plans and strategies.

f. business acquisitions, development expansion or capital investment plan activities.

g. software and any other confidential technical programs.

h. personnel information, employee payroll and benefits data.

i. accounts receivable and accounts payable.

j. other financial information, including financial statements, budgets, projections, earnings and any unpublished financial information.

k. company correspondence and communications and communications with outside parties; and

l. information, data and materials developed by Employee.

Primary Care Solutions of Ohio, Inc.

Confidentiality and Non-Disclosure Agreement continued

4. Statement of Property

Assignment of intellectual Property rights to Primary Care Solutions Employer agrees to assign and transfer to Primary Care Solutions his or her entire right title interest in and to any and all improvements, new ideas or concepts or other innovation made or developed by Employee "innovations" either solely or jointly with other during the course of employment. Employee agrees to make and maintain Adequate and current written records of all such Innovations in the form of notes or report relating thereto; which records shall be remaining the property of and be available to Primary Care Solutions at all times. Employee agrees to promptly Disclose so Primary Care Solutions all such innovations and shall not claim and Additional or special payment for such assignment.

5. Returns

Return of Confidential Information Upon Termination Upon termination of employment of whatever reason, Employee aggress to return Immediately to Primary Care Solutions (Employee Supervisor) any and all Confidential information, including copies, extracts or other reproductions, in Employee's possession or

6. This is Not a Contract of Employment

Agreement Does Not Constitute Contract of Employment Agreement Does Not Constitute Contract of employment Employee acknowledge that his Agreements address only the treatment of confidential Information and does not constitute A contract of employment not does it guarantee any continued employment of employees by Primary Care Solutions.

7. Survival

The termination of Employee's employment, for whatever reason, shall not Extinguish and obligations of Employee hereunder.

8. Enforcement of Agreement

Primary Care Solutions shall be entitled to specific performance and injunctive or other equitable relief for any breach of this agreement.

IN WITNESS WHEREFORE, Employee signed this agreement as of the data written below.

Primary Care Solutions of Ohio, Inc

Drug and Alcohol Policy

This policy is being distributed to all Primary Care Solutions employees in compliance with the provisions and the Drug-Free Workplace Act of 1988 (41 U.S.C; Section 701, et.seg

Individuals Covered by the Policy:

This policy applies to all employees (including hourly) who work at Primary Care Solutions and in workplaces controlled by Primary Care Solutions.

1. Policy Guidelines

A. Employees

Primary Care Solutions absolutely prohibits the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance or alcohol on company premises or while conducting company business off company premises. Violation of this policy may result in immediate termination of employment or other appropriate disciplinary actions. "Controlled substances" are those usually referred to as illegal drugs listed under the federal Controlled Substances Act.

B. Compliance with the Drug-Free Workplace Act of 1988

As a condition of employment, all staff must: Notify the Director of Human Resources of any conviction under a criminal drug statute for violations occurring on or off Primary Care Solutions premises while conducting company business. When the Department of Human Resources receives notice of such a conviction, it will coordinate efforts to comply with the reporting requirements of the Drug-Free Workplace Act of 1988.

2. Policy Enforcement An employee who: (1 Is found to be under the influence of alcohol or a controlled substance while on Primary Care Solutions property or in the course of company business; (2 Uses alcohol or controlled substances during working hours, or (3 Is convicted of a criminal alcohol or drug statute violation occurring on company property is subject to disciplinary action, up to and including termination.

Primary Care Solutions of Ohio, Inc.

HIPAA Compliance Form

The Health Insurance Portability and Accountability Act (HIPAA) is the Federal law that establishes standards for the privacy and security of health information. This law requires HIPAA training for all personal at Primary Care Solutions. Federal regulations also require documentation that each employee has received and read the training information that will

By signing and returning this form I confirm that I have received training and written documentation for Primary Care Solutions HIPAA Compliance Policy. I also hereby agree to adhere to all federal regulations and Primary Care Solutions policy in reference to HIPAA.

Acknowledgement of Primary Care Solutions Employee Handbook

I have received a copy of the Employee Handbook and have had the opportunity to read it or have had it read to me. I understand that I am responsible for the information contained in this handbook. I understand that this handbook is intended to provide a condensed version of the policies, procedures, rules and ethics most often applied to day-to-day work activities and has been prepared for the information and guidance of staff working at Primary Care Solutions. I understand that some of the information will change from time to time because policies are under constant review and are revised when appropriate. I understand that I will be notified in writing if the changes directly affect my employment or expectation of job performance. I understand that other changes will be discussed in staff meetings. I agree that my employment is terminable at will, so that both Primary Care Solutions and I remain free to end our work relationship. I understand that there is no guarantee of employment made to any staff member, either expressly or implies, in this handbook. (Click the Link to Read the PCS Employee Handbook, Primary Care Solutions Employee Handbook) I have read the title Code of Ethical Conduct and understand that I am responsible for the information it contains. I have been given the opportunity to ask questions about the policy.

PRIMARY CARE SOLUTIONS INC SAFETY HANDBOOK

Safety Handbook Acknowledgement

Please Click the Link and Read the Primary Care Solutions Safety Handbook. Primary Care Solutions Safety Handbook

Department of the Treasury Internal Revenue Service

Employee's Withholding Certificate

 

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Give Form W-4 to your employer. Your withholding is subject to review by the IRS.

Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

 

TIP: Consider using the estimator at www.irs.gov/W4App to determine the most accurate withholding for the rest of the year if: you are completing this form after the beginning of the year; expect to work only part of the year; or have changes during the year in your marital status, number of jobs for you (and/or your spouse if married filing jointly), dependents, other income (not from jobs), deductions, or credits. Have your most recent pay stub(s) from this year available when using the estimator. At the beginning of next year, use the estimator again to recheck your withholding. Complete Steps 2-4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, and when to use the estimator at www.irs.gov/W4App.

Step 2: Multiple Jobs or Spouse Works 

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs. Multiple Jobs or Spouse

Do only one of the following.

(a) Use the estimator at www.irs.gov/W4App for the most accurate withholding for this step (and Steps 3-4 If you or your spouse have self-employment income, use this option; or

(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below; or

(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is generally more accurate than (b) if pay at the lower paying job is more than half of the pay at the higher paying job. Otherwise, (b) is more accurate

 

Complete Steps 3-4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3-4(b) on the Form W-4 for the highest paying job

 

 

 

 

For Privacy Act and Paperwork Reduction Act Notice, see page 3.

Employment Eligibility Verification

Department of Homeland Security U.S. Citizenship and Immigration Services

START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form. See below and the Instructions. ANTI-DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form I-9. Employers cannot ask employees for documentation to verify information in Section 1, or specify which acceptable documentation employees must present for Section 2 or Supplement B, Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal. Section 1. Employee Information and Attestation: Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.

I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.

Check one of the following boxes to attest to your citizenship or immigration status (See page 2 and 3 of the instructions:

1. A citizen of the United States

2. A noncitizen national of the United States (See Instructions

3. A lawful permanent resident (Enter USCIS or A-Number (exp. date, if any) If you check Item Number 4., enter one of these:

4. An alien authorized to work until

If a preparer and/or translator assisted you in completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3.

Section 2. Employer Review and Verification: Employers or their authorized representative must complete and sign Section 2 within three business days after the employee's first day of employment, and must physically examine, or examine consistent with an alternative procedure authorized by the Secretary of DHS, documentation from List A OR a combination of documentation from List B and List C. Enter any additional documentation in the Additional Information box; see Instructions.

Check here if you used an alternative procedure authorized by DHS to examine documents.

Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the above-named employee, (2) the above-listed documentation appears to be genuine and to relate to the employee named, and (3) to the best of my knowledge, the employee is authorized to work in the United States.

For reverification or rehire, complete Supplement B, Reverification and Rehire on Page 4.

All documents containing an expiration date must be unexpired. * Documents extended by the issuing authority are considered unexpired. Employees may present one selection from List A or a combination of one selection from List B and one selection from List C. Examples of many of these documents appear in the Handbook for Employers (M-274

LIST A

Documents that Establish Both Identity and Employment Authorization

Documents that Establish Identity

1. U.S. Passport or U.S. Passport Card

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) 3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine- readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For an individual temporarily authorized to work for a specific employer because of his or her status or parole:

a. Foreign passport; and

b. Form I-94 or Form I-94A that has the following: (1) The same name as the passport; and (2) An endorsement of the individual's status or parole as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

OR

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, sex, height, eye color, and address

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, sex, height, eye color, and address

3. School ID card with a photograph

4. Voter's registration card

5. U.S. Military card or draft record

6. Military dependent's ID card

 

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

9. Driver's license issued by a Canadian government authority

For persons under age 18 who are unable to present a document listed above:

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

 

AND

 

LIST C Documents that Establish Employment Authorization 1. A Social Security Account Number card, unless the card includes one of the following restrictions:

(1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

2. Certification of report of birth issued by the Department of State (Forms DS-1350,

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4. Native American tribal document

5. U.S. Citizen ID Card (Form I-197)

6. Identification Card for Use of Resident Citizen in the United States (Form I-179)

7. Employment authorization document issued by the Department of Homeland Security For examples, see Section 7 and Section 13 of the M-274 on uscis.gov/i-9-central. The Form I-766, Employment Authorization Document, is a List A, Item Number 4. document, not a List C document.

Acceptable Receipts

 

May be presented in lieu of a document listed above for a temporary period. For receipt validity dates, see the M-274.

Receipt for a replacement of a lost, stolen, or damaged List A document.

Form I-94 issued to a lawful permanent resident that contains an

I-551 stamp and a photograph of the individual.

Form I-94 with "RE" notation or refugee stamp issued to a refugee.

*Refer to the Employment Authorization Extensions page on I-9 Central for more information.

Form W-9

(Rev. March 2024) Department of the Treasury Internal Revenue Service Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below. 1 Name of entity/individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner's name on line 1, and enter the business/disregarded entity's name on line 2

Request for Taxpayer Identification Number and Certification

Go to www.irs.gov/FormW9 for instructions and the latest information.

Give form to the requester. Do not send to the IRS.

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. See also What Name and Number To Give the Requester for guidelines on whose number to enter.

 

Part IICertification Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and, generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

GENERAL INSTRUCTIONS

Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.

What's New

Line 3a has been modified to clarify how a disregarded entity completes this line. An LLC that is a disregarded entity should check the appropriate box for the tax classification of its owner. Otherwise, it should check the "LLC" box and enter its appropriate tax classification.

New line 3b has been added to this form. A flow-through entity is required to complete this line to indicate that it has direct or indirect foreign partners, owners, or beneficiaries when it provides the Form W-9 to another flow-through entity in which it has an ownership interest. This change is intended to provide a flow-through entity with information regarding the status of its indirect foreign partners, owners, or beneficiaries, so that it can satisfy any applicable reporting requirements. For example, a partnership that has any indirect foreign partners may be required to complete Schedules K-2 and K-3. See the Partnership Instructions for Schedules K-2 and K-3 (Form 1065