Job  Reference 2 

Personal  Reference 1 

Personal  Reference 2

I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misinterpretation may result n rejection of my application. I authorized investigation of all statements contained in this application, as required.  Additionally, I authorized former employers, references and any other individual/organizations to provide information to Macas Home Care LLC and I hereby release and discharge any of the above and Macas Home Care LLC from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary.

I agree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with the Agency. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test and a criminal background check.

I further understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States.

I have been oriented to Macas Home Care LLC‘s Policies and Procedures.  I understand the Agency’s policies and procedures and hereby agree to abide by them. I understand that revisions to these policies & procedures may occur and it is my responsibility to adhere to all revisions, as stated.

OFFICE USE ONLY!!! DO NOT FILL IF YOU ARE AN APPLICANT.

I ACKNOWLEDGE that I have read and understand Macas Home Care LLC’s Policies and Procedures and agree to abide by them.

I agree to comply with the policies, regulations, and standards of:

• Federal, States and Local Laws
• The Health Insurance Portability & Accountability Act of 1996 (HIPAA)
• Professional Standards
• Relevant, Federally-Funded Healthcare Programs

I understand my responsibility to report:

• Any suspicions or observations of fraud or abuse in accordance with the Federal Deficit Reduction and False Claims Acts; and, any known or suspected HIPAA security incidents or violations.

I understand that revisions to these policies, procedures, laws, regulations, and standards may occur over time, and it is my responsibility to adhere to all revisions, as stated.

I understand that adhering to these policies , procedures, laws, regulations, and standards is a condition of employment and/or continued employment.

Furthermore, I understand that if I do not comply with these security policies and procedures, appropriate sanctions will be applies against me.

OFFICE USE ONLY!!! DO NOT FILL IF YOU ARE AN APPLICANT.

It is the responsibility of all Agency employees to preserve and protect confidential Agency, client, and employee medical, personal, and business information and, thus, shall not disclose such information except as authorized by law, client, or individual.

Confidential Client Information includes, but is not limited to any identifiable information about a client’s and/or his/her family including, but not limited to:

1. medical history;
2. mental, or physical condition;
3. treatments and medications;
4. test results;
5. conversations;
6. financial information; and,
7. household possessions.

Confidential Employee information includes, but is not limited to:

• contact information i.e. telephone number(s); address, email address;
• names of spouse and/or other relatives;
• Social Security Number;
• performance appraisal information;
• health status and treatments; and,
• other information obtained from their personnel files which would be an invasion of privacy e.g.:

• Date of Birth;
• Place of Birth
• Traditional password identifiers
• Bank account numbers
• Income tax records
• Driver’s license numbers
• Credit card numbers
• Passport numbers
• Confidential Business Information

Confidential business information includes, but is not limited to:

1. client lists;
2. security data and credentials such as passwords,
3. any information that, if released, could be harmful to the Agency; and,
4. any financial information including accounts receivable, accounts payable, and payroll.

I acknowledge that:

1. I understand that it is my legal and ethical responsibility to protect the security, privacy, and confidentiality of all client records, Agency information, and other confidential information relating to the Agency, including business, employment, and medical information about clients, their families, and employees.
2. I will only discuss confidential information during the performance of my duties and only for job-related purposes and shall take caution to ensure such conversations are not within hearing range of anyone who is not entitled to have this information
3. I shall respect and maintain the confidentiality of all discussions, conversations, and any other information generated while providing service to clients in connection with individual client service, risk management, and/or peer review activities.
4. I shall not disclose the content of any discussions, deliberations, client records, peer reviews, or risk management information, except to persons authorized to receive such information, while conducting Agency business.
5. I shall only access or distribute client care information when executing my job duties or when required to do so by law.
6. I will only access records on a “need-to-know” basis in the performance of my duties.
7. I will not share my Login or User ID and password for accessing electronic records with anybody. If I believe someone else has used my Login or User ID and/or password, I will immediately notify the Supervisor.
8. I will only use mobile computing devices, with Agency approval, providing they are encrypted with an approved data encryption solution before using them for any Agency-related business. I understand that I may be personally responsible for any breach of confidentiality resulting from unauthorized access due to hacking or other means to Agency information stored on my unencrypted device
9. I understand that the Agency will undertake measures to determine if client and employee records have been accessed without authorization.
10. I understand that state and federal laws/regulations governing a client’s right to privacy, the illegal or unauthorized access or disclosure of a client’s confidential information may result in disciplinary action up to and including immediate termination from my employment and possible civil fines and criminal sanctions.
11. I understand that I am obligated to maintain these confidentialities after my employment with this Agency ceases.

I hereby acknowledge that I have read and understand the above-mentioned information and that my signature below indicates my agreement to comply with these terms.

 OFFICE USE ONLY!!! DO NOT FILL IF YOU ARE AN APPLICANT.

Please be advised that you are responsible for your background check fee. A total amount of thirty U.S dollars($30.00) for background check will be deducted from your first paycheck. Please note that endorsing this section of the application form with your signature gives Macas Home Care LLC the consent to deduct the background check fee($30.00) from your first paycheck.

I understand that as part of the employment process, Macas Home Care LLC needs to complete a background check on me regarding:

1. Criminal record;
2. Sex and Violent Offenders Record;
3. Employment Verification;
4. Education Verification;
5. License Verification;
6. Motor Vehicle Records,
7. Personal/Professional Reference Verification;
8. Medical Suitability;
9. Drugs/Alcohol;
10. Child Abuse Clearance (if indicated)

• I authorize all federal and state agencies, persons, and organizations that may have information relevant to this research to disclose such information to Macas Home Care LLC or its authorized agent(s).
• I understand that this authorization is to be part of the written and signed employment application.
• I also understand that I do not have to give authorization for a background check but if I don’t give permission, my employment application will not be processed further.
• I understand that I have specific rights under the federal Fair Credit Reporting Act (FCRA) and may have additional rights under relevant State law.
• I further authorize that a photocopy of this authorization may be considered as valid as the original.

OFFICE USE ONLY!!! DO NOT FILL IF YOU ARE AN APPLICANT.

Macas Home Care LLC has recommended that I receive an influenza vaccination to protect myself and the clients I serve.

I acknowledge that I am aware of the following facts:

• Influenza is a serious respiratory disease that kills an average of 36,000 persons and hospitalizes more than 200,000 persons in the United States each year.
• Influenza vaccination is recommended for me and all other healthcare workers 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 infections to clients.
• If I become infected with influenza, even when my symptoms are mild, I can spread severe illness to others.
• I understand that that the strains of virus that 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;
• Clients;
• my co-workers
• my family
• my communit

OFFICE USE ONLY!!! DO NOT FILL IF YOU ARE AN APPLICANT.

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine, at no charge to me; 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 serious 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 series at no charge to me.

OFFICE USE ONLY!!! DO NOT FILL IF YOU ARE AN APPLICANT.

Macas Home Care LLC has recommended that I receive a Covid-19 vaccination to protect myself and the clients I serve.

I acknowledge that I am aware of the following facts:

• Covid-19 is a serious respiratory disease that killed an average of 1,011,013 persons and hospitalized more than 25,621 persons in the United States as of June of 2022.
• Covid-19 vaccination is recommended for me and all other healthcare workers to prevent Covid-19 disease and its complications, including death.
• If I contract Covid-19, I will shed the virus for 24-48 hours before Covid-19 symptoms appear. My shedding the virus can spread Covid-19 infections to clients.
• If I become infected with Covid-19, I can spread severe illness to others even when my symptoms are mild.
• I understand that the strains of the SARS-COV-2 virus that cause Covid-19 infection change almost every year, which is why a booster of Covid-19 vaccine is recommended after the first shot.
• I cannot get the Covid-19 disease from the Covid-19 vaccine.
• The consequences of my refusing to be vaccinated could endanger my health and the health of those with whom I have contact, including:
• Clients
• my co-workers
• my family
• my community

OFFICE USE ONLY!!! DO NOT FILL IF YOU ARE AN APPLICANT.