Personal Information Policy:
I accept Suma Home Care, Inc. offer of employment. I agree and acknowledge that my relationship with Suma Home Care, Inc. is that of an at-will employee, meaning that either Suma Home Care, Inc. or I may terminate the relationship at any time, with or without reason or for no reason. I agree and acknowledge that this offer letter is not a promise or contract of employment, and that this offer of employment may be rescinded at any time prior to my start date.
I certify that any and all information submitted in this application, resume or other information for which I have provided and any statements which I make during any interview are true and accurate to the best of my knowledge. Nor will I withhold any information that would affect my application for employment. I understand that there is no obligation to consider or reconsider this application at any time and that acceptance of this application does not constitute an offer of employment.
I authorize that inquiries may be made with my previous educators, employers, references, consumer credit, private or government agencies and any other individuals who may have knowledge of me or my work experience. I give my consent for any such person or agency to give any and all information concerning my previous employment, including but not limited to an assessment of my job performance, ability, fitness and/or other information they may have, personal or otherwise. I agree to cooperate with such an investigation and release all parties from any and all liability, claims or damages, directly or indirectly, resulting from furnishing such information. Upon my written reasonable and timely request, a description of the general scope and nature of any such inquiry will be provided to me.
I hereby certify that the facts set forth in this employment application are true and complete to the best of my knowledge. I understand that, if I am employed, any falsified statements on this application or misleading information during the interview process may result in my immediate dismissal at any time.
I also understand that failure to complete this application in its entirety may result in disqualifying the application from employment consideration or, if employed, termination from employment.
I understand that the nature of employment at Suma Home Care, Inc. may bring me into contact with clients’ personal possessions and medications, and I hereby authorize Suma Home Care, Inc. to obtain a consumer report for purposes of hiring, investigating, assigning, or retaining me as an employee at any time during my employment.
I further recognize that my health and physical condition is a legitimate concern of Suma Home Care, Inc. and I consent to submit to such physical examinations as Suma Home Care, Inc. may require at any time, as conducted by a physician or other health professional designated and paid for by Angels on Call. I understand that failure to submit to such an examination may result in the denial of employment or dismissal, if employed, by Angels on Call. I hereby consent to have the results of such examinations released to Angels on Call.
In consideration of my employment, I agree to conform to the rules and regulations of Suma Home Care, Inc. and acknowledge that my employment and compensation can be terminated with or without cause, and with or without notice, at any time at the option of either Suma Home Care, Inc. or myself. I acknowledge that I may be hired as a part-time or full-time employee; because of the nature of health care, full-time hours cannot be guaranteed.
Suma Home Care, Inc. is a drug free workplace. All offers of employment are subject to post offer general physicals, drug testing, and a criminal background check.
Additionally, I hereby authorize Suma Home Care, Inc. to conduct a full investigation into my employment history, education, and activities. I release Suma Home Care, Inc. and all parties involved from all liability or responsibility for damages of any nature which may arise at any time, all companies, corporations, and/or individuals supplying information that will be used to determine my qualifications for employment.
AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT OF PAYCHECK
This authorization is to remain in effect until Suma Home Care, Inc. has received written notification from me of its termination in such time and in such manner as to afford Suma Home Care, Inc. a reasonable opportunity to process the request. I agree to notify Human Resources before closing this account.
CONFIDENTIALITY OF PATIENT INFORMATION
ALL affiliates and guests of Suma Home Care, Inc. are expected to maintain strict confidentiality concerning patients and residents. NEVER discuss information about patients unless it is strictly necessary to perform assigned duties.
Our patients entrust themselves to the care of Suma Home Care, Inc. with complete confidence. You may be approached for information by patients or by a person who is not an employee of Angels on Call. Whatever the case, please remember:
Respect the right of privacy as recognized by law, as well as a person’s right to be left alone.
Refrain from idle conversations about the patient, his/her condition, or his/her personal affairs with your co-workers, patients or other individuals.
Refer inquiries from outside of Suma Home Care, Inc. to appropriate business personnel.
I understand that any protected health information I view or come in contact with is subject to HIPAA and is confidential and I am aware that indiscriminate sharing of patient information is not permitted. I will maintain confidentiality of patient protected health information and will use such information only to the extent necessary.
This is to certify that I have read, understood and agree to abide by the above policy.
WORKERS’ COMPENSATION:
I have been notified by my employer of the procedure to follow in the event I incur a work-related injury or illness. I understand that my employer has a designated Workers’ Compensation Insurance Carrier that will handle all Workers’ Compensation-related matters, including work-related injuries and illnesses. I have been advised that I must immediately notify Suma Home Care, Inc. management regarding any injury that I may sustain on the job.
I understand that if I do not receive my medical care for work-related injuries and illnesses from designated doctors and medical organizations, I may be financially responsible for that care.
I have been informed that authorization is required from my employer before I access medical care for non-emergency, work-related injuries and illnesses. I recognize that I should contact the Human Resources department with any questions.
Insurance Fraud can occur when a person willfully and knowingly attempts to collect benefits they are not entitled to. Fraud can be committed by falsifying information and exaggerating losses. Insurance Fraud will be forwarded to the Office of Attorney General for full investigation and possible criminal prosecution.
I9:
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
W4:
Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
AUTHORIZATION TO OBTAIN INFORMATION Background Screening:
In connection with my application for employment with Angels on Call, I understand that prior to or at any time after my employment commences a Consumer Report may be requested for employment purposes from public and private sources; such reports may include, without limitation, information concerning your Social Security number, motor vehicle operation history and criminal history to the extent permitted by law from various local, state, and federal agencies. Further, I understand that a Investigative Consumer Report may be requested and, as required under §1681d(a)(1), I understand that this Report will include information as to my character, general reputation, personal characteristics, mode of living, work habits, performance, experience, along with reasons for termination of past employment, whichever are applicable, obtained through personal interviews with associates who have knowledge concerning such items of information; such information will be obtained from personal interviews with your business associates, former employers or co-employees, or other persons with relevant knowledge.
I VOLUNTARILY AND KNOWINGLY AUTHORIZE ANY PRESENT OR PAST EMPLOYER OR SUPERVISOR; COLLEGE OR UNIVERSITY OR OTHER INSTITUTION OF LEARNING; ADMINISTRATOR; LAW ENFORCEMENT AGENCY, STATE AGENCY, LOCAL AGENCY, FEDERAL AGENCY; CREDIT BUREAU; PRIVATE BUSINESS; MILITARY BRANCH OR THE NATIONAL PERSONNEL RECORDS CENTER; PERSONAL REFERENCE; AND/OR OTHER PERSONS TO GIVE RECORDS OR INFORMATION THEY MAY HAVE CONCERNING MY CRIMINAL HISTORY, MOTOR VEHICLE HISTORY, SOCIAL SECURITY NUMBER, EARNINGS HISTORY, CHARACTER, AND EMPLOYMENT (INCLUDING REASONS FOR TERMINATION) OR ANY OTHER INFORMATION REQUESTED BY THE PA STATE POLICE, SUMA HOME CARE, INC. AND ANY OTHER AGENCY CONTRACTED BY SUMA HOME CARE, INC. TO PERFORM BACKGROUND SEARCHES.
In accordance with the Fair Credit Reporting Act, the California Consumers Investigative and Credit Reporting Agencies Acts, and the Federal Trade Commission staff opinions, I understand that I have the right to request a complete and accurate disclosure of the nature and scope of the investigation requested. Further, I am entitled to know if employment is denied because of information obtained by my prospective employer from a Reporting Agency. If so, I will be so advised in writing and be given the name, address and toll free number of the agency, a statement that the action was based in whole or in part on information contained in the Report, and written notice that I have the right (i) if I request, to obtain within sixty days a free copy of the Report from the Reporting Agency (under no circumstances shall such cost exceed the actual costs of duplication), and from any other Consumer Reporting Agency which compiles and maintains files on consumers on a nationwide basis; and, (ii) to dispute the accuracy or completeness of any information in a consumer report furnished by the Reporting Agency.
I understand that upon my request with reasonable notice and after furnishing proper identification, Suma Home Care, Inc. will provide me with investigative information in my file during normal business hours in person or upon written request, by certified mail to a specified addressee, or telephone as permitted by law. Further, I understand that I should I wish to review my file in person; I am permitted to be accompanied by one other person of my choosing who shall furnish reasonable identification. I understand that any Consumer Report or Investigative Consumer Report requested will be used strictly for employment purposes as defined under §603(h) and authorized under §604(a)(3)(B) of the Fair Credit Reporting Act, as a report to be used for the purpose of evaluation for employment, promotion, reassignment or retention as an employee.
I further understand that request for workers’ compensation information shall be after a conditional job offer is made and may include “any and all”
injuries pursuant to state law and in compliance with the Federal Americans with Disabilities Act. In addition, any offer of employment, promotion, or reassignment will be conditional upon the receipt of satisfactory information as required and that to be considered for employment, promotion, or reassignment; I must authorize the procurement of such Report(s). A photographic or faxed copy of this form shall be as valid as the original. I understand that by signing below, I am authorizing Suma Home Care, Inc. to obtain information ONLY in the following areas: Criminal History, Child Clearances, Social Security # verification, Motor Vehicle Report, Workers Compensation, Professional License # verification (where applicable), and Education (where applicable). Prescreening for the Pennsylvania Work Opportunity Tax Credit Program will be collected via telephone call to tax screening vendor or via an internet portal linked to the tax screening portal. Clearances are property of Suma Home Care, Inc. and will not be distributed to employees or transferred to other corporate entities.
PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION
I affirm that the above information is accurate and complete to the best of my knowledge and belief and submitted as true and correct under penalty of law (Section 4904 of the Pennsylvania Crimes Code). If I selected volunteer, I understand that I can only use the certificate for volunteer purposes.
I understand that the injections must be given in a series of three (3) shots. The second shot must be given exactly thirty (30) days after the first shot and the third shot must be given one hundred fifty (150) days after the second shot. Since Suma Home Care, Inc. is paying for the vaccination, I understand that I must follow this schedule.
HEPATITIS B CONSENT/DECLINATION
I understand that if I miss ANY of the scheduled shots that the serum will not be effective and that I must go through the whole series again. I can not go through the series again until I have reimbursed Suma Home Care, Inc. the contractual rate per shot already received.
I understand that there are always risks involved with vaccines and that I will not hold Suma Home Care, Inc. responsible for any reaction or illness that results from the vaccinations.
I understand that due to my occupational exposure to blood and other potentially infectious material that I may be at risk of acquiring the Hepatitis B (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine, at no charge to myself. However, I decline the Hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at risk of acquiring Hepatitis B, a incurable disease.
If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination at no charge to me, in accordance with the conditions outlined above.
2022-2023 WAIVER OF COVERAGE:
I acknowledge that I have been offered the opportunity to enroll myself and eligible family members in Harrisburg Home Health Holdings LLC., Philadelphia Home Health Services, LLC., DC Home Health Services, LLC., LHCSA Home Health Services, LLC., Quality Healthcare Inc., Allhealth Home Care, LLC., and Quality Family Care, LLC. Plans, By not electing coverage you cannot make another elections until the plan’s next open enrollment next year unless you have a qualifying change in status. Please note that if the company does not receive your completed form you will be deemed to have declined the coverage offered to you and eligible dependents.