Caregiver Employment Application

Source transcription for review. The original packet controls; final applicability must be approved before launch.

CONFIDENTIALITY	STATEMENT	I	acknowledge	that	I	have	read	and	understood	FLORIDA	CONCIERGE	HOME	 CARE	,	 here	 in	 referred	 to	 as	 Registry,	 Confidentiality	 Policy,	HIPAA	regulations	and	the	Privacy	Statement.	I	acknowledge	that	during	my	 employment/placement/volunteer/project	 work	 with	Registry	I	may	have	access	to	confidential	information.	I	acknowledge	that	it	is	a	term	and	condition	of	my	work	with	Registry	that	I	will	at	all	times	respect	the	privacy	of	clients	and	their	families,	students,	 volunteers	 and	 employees,	 and	 the	 confidential	 nature	 of	the	business	of	Registry.	I	will	closely	protect	confidential	information	to	prevent	it	being	inappropriately	accessed,	used	or	disclosed	either	directly	by	me,	or	by	virtue	of	my	password	to	systems,	or	by	permitting	breaches	in	physical	security	to	occur.	If	I	become	aware	of	any	violation	of	confidentiality,	or	lose	any	record	containing	confidential	information	or	any	key	or	other	item	that	could	be	used	to	violate	confidentiality,	I	will	notify	my	supervisor	or	another	responsible	Registry	supervisor	at	 the	 first	 reasonable	 opportunity.	 I	 understand	 that	 violations	 to	confidentiality	may	include,	but	are	not	limited	to:	- Accessing	personal	or	organizational	information	that	I	do	not	require	in	order	to	properly	carry	out	my	duties;	- Using	or	disclosing	personal/organizational	information	(verbally,	
through	 the	 computer	 system,	 or	 in	 hard	 copy)	 without	 proper	authorization;	- Inappropriately	sharing	passwords,	keys,	codes	or	other	identification	devices	without	proper	authorization.	I	 will	 only	 access,	 use,	 transfer	 or	 disclose	 private	 and	 confidential	information	as	required	by	the	duties	of	my	position.	I	agree	to	cooperate	with	 Registry	 in	 any	 audit	 or	 investigation	 relating	to	 confidential	information	 and	 to	 provide	 any	 records	 requested	 in	 connection	with	such	audits	or	investigations.	I	understand	and	agree	to	abide	by	the	 conditions	 outlined	 in	 this	 agreement	 both	 during	 and	 after	 my	employment	or	association	with	Registry.	I	understand	that	a	violation	of	this	agreement	may	result	in	disciplinary	action	that	may	include	termination/dismissal	from	employment	or	association	with	Registry,	or	that	I	may	be	subject	to	civil	or	criminal	liability.	I	understand	that	no	information	is	to	be	released	without	the	written	“Release	of	Information”	consent	signed	by	the	patient	or	patient’s	legal	representative.	It	is	understood	that	breaks	in	the	policies	and	procedures	of	Registry	concerning	confidentiality	may	result	in	immediate	terminate	without	put	further	notice.			 	 	
Name	(Please	Print)	 Date		Applicant	Signature	
BACKGROUND	CHECK	AUTHORIZATION	I	 voluntarily	 consent	 to	 and	 authorize	FLORIDA	 CONCIERGE	 HOME	CARE,	here	in	referred	to	as	Registry,	and	or	their	assigned	agents,	associates,	or	 consumer	 reporting	 agencies	 to	 request	 and	 receive	any	 criminal	background	reports,	consumer	reports,	investigative	consumer	reports	 containing	information	as	to	my	character,	general	reputation,	personal	characteristics	 and	 mode	 of	 living,	 or	 information	concerning	 me	 as	 part	of	the	pre-employment	background	review	process.	Reports	requested	may	include	any	of	the	following:	Law	Enforcement	Records,	Criminal	 Records,	 Civil	 Records,	 Motor	Vehicle/	Driving	 Records,	 Credential	Verification,	Employment	Verifications,	Past	Employment	Verifications,	Education	 Verifications,	Reference	 Checks,	 Military	 Service	 Verifications,	and	Consumer	Credit	Reports	in	accordance	with	the	provisions	of	the	Fair	Credit	Reporting	Act	and	similar	State	laws.	I	 authorize	 any	 persons,	 organizations,	 companies,	 corporations,	consumer	reporting	agencies,	courts	of	law,	licensing	agencies,	schools,	and	 any	 current	 or	 past	 employer	 to	 furnish	 Registry	 and	 or	 their	assigned	agents,	associates	or	consumer	reporting	agencies	with	any	and	all	information	concerning	me.	I	further	agree	to	release	Registry	and	or	their	assigned	agents,	associates,	or	consumer	reporting	agencies	and	all	persons	and	organizations	providing	information	from	any	and	all	claims,	liability	and	responsibility	arising	out	of	the	release	of	such	information	in	connection	with	this	research.	
This	authorization	shall	remain	on	file	and	shall	serve	as	an	ongoing	authorization	 for	 Registry	 to	 procure	 criminal	records,	 consumer	reports,	including	investigative	consumer	reports,	at	any	time	during	the	contracting	period.	By	signing	below,	I	hereby	release	Registry,	its	employees,	 agents,	 and	 all	 persons,	 agencies	 and	 entities	 providing	information	or	reports	about	me	from	any	and	all	liability	arising	out	of	the	release	of	any	such	information	or	reports.	I	 understand	 that	 if	 an	 adverse	 decision	 on	 my	 application	 for	employment	is	made,	based	in	whole	or	in	part	on	information	contained	in	any	consumer	report,	I	will	be	so	informed.	I	will	also	be	provided	an	opportunity	to	obtain	a	copy	of	that	consumer	report	and	to	dispute	any	inaccurate	or	incomplete	information.	I	agree	that	a	photocopy,	facsimile,	or	other	electronic	forms	of	this	information	 can	 be	 furnished	 to	 Registry,	 and	 that	 it	 will	 have	 the	same	authority	and	authenticity	as	the	original.	I	also	understand	that	any	misrepresentation,	falsification	or	omission	of	facts	herein	may	be	considered	cause	for	rescinding	and	offer	of	employment,	termination	of	employment,	or	denial	of	consideration	for	future	employment.	
		 	 	
Name	(Please	Print)	 SSN		Applicant	Signature	 DOB			 	Date	Other	names	under	which	previously	employed	(Print	Name)