Med-Corp Plus Job Application Atoka

Med-Corp Plus

Application for Employment Atoka

First Name
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Middle Name
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Last Name
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Maiden Name (if not applicable, enter "NA")
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What other Aliases/Names have you used? (or "NA")
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Address
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City
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State
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Zip
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Upload a copy of your Driver's License
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Upload a copy of your Social Security Card
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What position are you interested in?
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List most recent employer, city, job title and phone
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List second most recent employer, city, job title and phone
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List two references: name, years known, relationship and phone
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List emergency contact(s) and phone numbers(s)
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List past Eduction (High School, College, Trade Schools, etc.)
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List your email address
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Social Sec Number
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Ethnicity (Black, White, Hispanic, Native American, etc)
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Marital Status
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Spouse Name and Phone number (Enter NA if not applicable)
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ACCIDENT/INCIDENT

1. UNLESS AN INCIDENT IS A LIFE THREATENING SITUATION, YOU MUST CALL YOUR SUPERVISOR BEFORE SEEKING MEDICAL CARE.

2. BE PREPARED TO ANSWER QUESTIONS PERTAINING TO THE INCIDENT INCLUDING WHERE, WHY, HOW, WITNESSES, ETC.

3. YOUR SUPERVISOR WILL INFORM YOU OF THE NEXT STEPS TO TAKE WHICH MAY BE SIMPLE FIRST AID OR A VISIT TO A PHYSICIAN OR ER.

4. IN ANY WORK COMP CASE, YOU WILL BE GIVEN A RELEASE TO RETURN TO WORK BY THE PHYSICIAN.  WITHOUT THIS RELEASE, YOU MAY NOT RETURN TO WORK.  IT MUST BE FAXED TO THE OFFICE OR BROUGHT BY AS SOON AS POSSIBLE.  WE MUST HAVE A COPY OF ANY PAPERWORK GIVEN TO YOU BY THE PHYSICIAN.

5. PROTOCOL MUST BE FOLLOWED TO ENSURE THAT YOUR CLAIM WILL NOT BE VOIDED.     Date:
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CONDITIONS OF PROVIDER PARTICIPATION

CODE OF ETHICS
No use of member’s car;
No consumption of the member’s food or drink (except water);
No use of the member’s telephone for personal calls;
No discussion of own or other’s personal problems, religious or political beliefs with member;
No acceptance of gifts or tips from the member;
No friends or relatives brought to the member’s home; No consumption of alcoholic beverages nor use of medicine or drugs for any purpose other than medical in the member’s home or prior to service delivery;
No smoking or vaping in the member’s home;
No solicitation of money or goods from the member;
No breech of the member’s privacy or confidentiality or records;
No purchase of any item from the member, even at fair market value;
No assumption of control of the financial and/or personal affairs of the member;
No removal of anything from the member’s home;  
No use of the Member's vehicle
No use of the Member's personal possessions, not required for service delivery
No use of the Member's electronic devices
No weapons of any kind shall be taken into the Member's home

No abuse, neglect, or exploitation of the member.   Date:
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ORIENTATION STATEMENT

I acknowledge that I have been given an opportunity to review Med-Corp Plus, Inc. policy and procedure manual as part of my orientation.  I am aware that these policies may change and that I am responsible for reading any new policies.  The policy and procedure manuals will be available to me through my supervisor during office hours, upon request.                        Date:
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PERSONAL CARE ASSISTANT - Job Description:

1. Performs care and assists members in all activities of daily living/personal care to help maintain their physical and emotional well being as written in the plan of care.
2. Prepares nutritious meals within the members’ diet restriction/s.
3. Performs light home making chores, shopping/errands and laundry as written in the members plan of care. 
4. Assists member with transfers and ambulation as written in the plan of care.
5. Use equipment safely and properly (i.e. side rails and assistive devices).
6. Complies with the use of the EVV AuthentiCare app to check in/out as required.
7. Satisfactorily perform assigned tasks as observed through competency evaluation/s as well as annually evaluated by an Agency licensed nurse.
8. Presents a favorable Company image while in the members’ home by being courtesy, neat and clean and having good personal hygiene.
9. Has dependable, insured transportation and access to a working phone.

Job Limitations:
1. May NOT administer any medications or prefill insulin syringes.
2. May NOT perform any sterile procedure/ wound care.
3. May NOT perform procedures requiring the knowledge of a licensed nurse.
4. May NOT transport the member at any time. 

Physical Requirement:
Must be able to lift over 30 pounds.

I, understand that the job description shall be considered an integral part of my employment contract, and do agree to abide by these to the best of my ability. In accordance with this agreement I shall receive compensation as follows.

$13.00 per hours (bi-monthly pay periods)    Date:
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MEMBER BILL OF RIGHTS

AS A MEMBER YOU HAVE THE RIGHT:

• To receive considerate and respectful care of person and property
• To participate in the development of your plan of care, including an explanation of any services proposed and of alternate services that may be available in the community.
• To receive complete and written information on your plan, including the name of the supervisor responsible for your services and to be notified in advance of any changes in your services.
• To refuse medical treatment or other services provided by law and to be informed of the possible results of your actions.
• To privacy and confidentiality about your health, social and financial circumstances.
• To know that all communications and records are treated confidentially.
• To expect that all in-home care personnel within the limits set by our plan will respond in good faith to your requests for assistance in the home.
• To receive information on an agencies policies and procedures including information costs, qualifications of personnel and supervision.
• To home care as long as needed or authorized.
• To examine all bills for service regardless of source/s of payment.
• To receive nursing supervision of the Personal Care Assistant to assure competency.
• To periodically have your services monitored for quality and satisfaction.
• To be in control of your own environment and life style.
• To freedom from all discrimination, including age, sex, ethic, life style, or medical.
• To be informed of living wills or Durable Power of Attorney to assist you in making informed choices about your health in the event you are no longer able to.
• To a prompt response from your Home Care provider to any questions or problems which occur during the course of your treatment.

If at any time you are dissatisfied with the care being provided to you, or we are unable to provide you with any requested information, please feel free to call or write to the address listed below:

SPECIAL HEALTH SERVICES
OKLAHOMA DEPARTMENT OF HEALTH
1000 N.E. 10th STREET
OKLAHOMA CITY, OKLAHOMA 73117
PHONE TOLL FREE 1-800-234-7258  
Date:
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Date of Birth
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State of Birth/Country
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US Citizen?
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Gender
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Height
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Weight
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Hair Color
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Eye Color
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Phone Number 
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Phone Type
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In what other states have you lived after 17 years of age?
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Consent and Release Form 
Crimes That May Block Your Employment 
Long Term Care Security Act – Title 63 O.S. Section 1-1945 et. seq. 
You must be fingerprinted to work with this employer. We will do a national background check and an arrest in any state is reviewed. Your fingerprints will be used to check the criminal history records of the FBI. The FBI will retain your fingerprints and associated information/biometrics and, while retained, your fingerprints will continue to be compared against other fingerprints submitted to, or retained by, the FBI.  If convicted for a crime listed below, you may not be able to work for nursing, assisted living, adult day care, and residential care facilities; homes for the developmentally disabled; group homes; home health and hospice agencies. These crimes apply to nurse aides, activity, social services, kitchen, housekeeping, maintenance and other non-licensed jobs. Licensure Boards define the crimes that apply for licensed health care professionals.  Tell this provider if you were fingerprinted for your license. Your arrest history will be monitored. If sentenced for any disqualifying crimes while employed you may lose your job.  Do you understand this?
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You will be found not eligible for a job with these employers if you were ever sentenced for one of the following crimes or a related crime: 1
a. abuse, neglect or financial exploitation of any person entrusted to the care or possession
of such person,
b. rape, incest or sodomy, 
c. child abuse, 
d. murder or attempted murder, 
e. manslaughter, 
f. kidnapping, 
g. aggravated assault and battery, 
h. assault and battery with a dangerous weapon, or 
i. arson in the first degree.
j. human trafficking   
 
You will be found not eligible for a job with these employers if you were ever sentenced for one of the following crimes or a related crime and less than five (5) years has passed since you completed the terms of your sentence, including any period of deferment 2:
a. assault, 
b. battery, 
c. indecent exposure and indecent exhibition, except where such offense disqualifies the applicant as a registered sex offender, 
d. pandering, 
e. burglary in the first or second degree, 
f. robbery in the first or second degree, 
g. robbery or attempted robbery with a dangerous  weapon, or imitation firearm, 
h. arson in the second degree, 
i. unlawful manufacture, distribution, prescription, or dispensing of a Schedule I through V drug as defined by the Uniform Controlled Dangerous Substances Act, 
j. grand larceny, or 
k. petit larceny or shoplifting.
l. human trafficking  
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1 If the results of a criminal history background check reveal that the subject person has been convicted of, pled guilty or no contest to, or received a deferred sentence for, a felony or misdemeanor offense for any of the following offenses in any state or federal jurisdiction, the employer shall not hire or contract with the person. [63 O.S. § 1-1950.1(C)(1)]
2 If less than five (5) years have elapsed since the completion of sentence*, and the results of a criminal history check reveal that the subject person has been convicted of, or pled guilty or no contest to, a felony or misdemeanor offense for any of the following offenses, in any state or federal jurisdiction, the employer shall not hire or contract with the person [63 O.S. § 1-1950.1(C)(2)]
* The law defines "Completion of the sentence" to mean the last day of the entire term of the incarceration imposed by the sentence including any term that is deferred, suspended or subject to parole [63 O.S. § 1-1950.1(A)(5)]  Do you understand this?
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Consent and Release Form Page 2 
This form is a provided as a courtesy for the use of employers. Other versions are allowed to meet Title 63 O.S. § 1-1947(H), which requires that an applicant shall provide the employer a government photo identification of the applicant and written consent for the employer to conduct a registry screening and the [Okla. State Bureau of Investigation (OSBI)] to conduct a state and national criminal history record check under this section. The employer shall maintain the written consent and information regarding the individual’s identification in their files for audit purposes. It is recommended a copy of the identification be maintained with the applicant's written consent.  
EMPLOYER MUST RETAIN THIS SIGNED APPLICANT CONSENT. 
Instructions to Applicant: [63 O.S. 1-1945 et. seq.] Evidence of an applicant's consent to a check of state and/or national licensure, certification, abuse, exclusion and offender registries, and fingerprinting for a state and national criminal history records check is required. If you have an active employment history in OK-SCREEN, new fingerprints may not be needed. New registry checks must be done. With your consent, the employer will submit your information through the OK-SCREEN web portal for checks against state and national registries. If you are cleared, and the employer wishes to continue, you will get an email or telephone notice to schedule an appointment for fingerprinting, if required. You will be responsible for a Ten Dollar ($10) processing fee at the time the appointment is scheduled unless the employer elects to pay the fee. You will have ten (10) calendar days to submit your fingerprints or you will be required to start over [63 O.S. § 1-1947(I)(4)]  Do you understand this?
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Declarations: By signing this form I consent to registry screening and submission of my fingerprints to the OSBI for forwarding to the Federal Bureau of Investigation for the purpose of conducting a state and national criminal history records check pursuant to 63 O.S. § 1-1947(H). I understand that the results will be shared with the Oklahoma National Background Check Program (ONBCP) operated by the Oklahoma State Department of Health (OSDH). I understand that if my criminal history results reveal information that prevents the Department from 
making a final determination, I will be given notice and will have sixty (60) days to make corrections or additions.  If I am unable to make corrections or additions within the sixty (60) days, the Department will either deny me 
eligibility based on the disqualifying results or advise me they cannot make a determination and notify me of my right to appeal. The notice shall include the reasons I was found not eligible for employment and a statement that I have a right to appeal. [63 O.S. § 1-1947(K)]  I understand that as a condition of employment, I agree to report to the employer immediately upon being 
arraigned, indicted, convicted, or pleading guilty or nolo contendere to one or more of the criminal offenses applicable to my license, certification, permit or employment class; or upon being the subject of a substantiated 
finding on a registry as described in this Consent and Release and Title 63, Section 1-1947. I understand an arraignment may also be cause for employment restrictions or termination. [63 O.S. § 1-1947(Q)]  Do you understand this?
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FBI Privacy Act Statement 
Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be
compared against other fingerprints submitted to or retained by NGI.  Do you understand this?
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Consent and Release Form Page 3 
Oklahoma National Background Check Program - 
Select Volunteer Employee Type in OK-SCREEN 
Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.  Do you understand this?
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I understand the OSDH will store the records of an employer’s enrolled employees, the results of the screening and criminal arrest records search, and an identifier issued by the OSBI for the purposes of receiving an automatic notification from the OSBI if a subsequent criminal arrest record submitted into the system matches a set of fingerprints previously submitted. When there is a match, the OSBI will notify the Department and the Department will notify the employee. This information is confidential, is not subject to disclosure under the Oklahoma Open Records Act, and shall not be disclosed to any person except for purposes of this act or for law enforcement purposes. I will promptly respond to Department inquiries regarding the status of an arraignment or indictment. Your employer must submit your name, any aliases, address, former states in which you resided, social security number, and date of birth. Providing the requested information is voluntary; however, failure to furnish the information may affect timely completion or approval of your application.   Do you understand this?
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My signature acknowledges that I have read, understand and accept the terms and conditions outlined in this form. I consent to registry screening and submission of my fingerprints to the OSBI for forwarding to the FBI.  Both agencies will conduct a state and national criminal history records check and retain my fingerprints for comparison against other fingerprints submitted to, or retained by, the OSBI or FBI. I received an Attachment to this form: "How to Request My Criminal History Report and Complete, or Challenge the Information."  Furthermore, I authorize Med-Corp Plus to contact my references and past employers, and my past employers to release information pertaining to my employment.
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