Disclosure Regarding Consumer Reports

Required by the federal Fair Credit Reporting Act, 15 U.S.C. § 1681b(b)(2)(A). This is a standalone disclosure — it appears separately from any other document, contains no other waivers or releases, and must be signed before any consumer report is obtained for employment purposes.

You have the right to request additional information about the nature and scope of any investigative consumer report. You may also obtain a copy of any report received about you from the consumer reporting agency that prepared it.

For more information about your rights under the Fair Credit Reporting Act, please review "A Summary of Your Rights Under the Fair Credit Reporting Act", which is also available at consumerfinance.gov.

Attestation of Compliance with Background Screening Requirements

Florida AHCA Form 3100-0008 · July 2024 · Rule 59A-35.090, Florida Administrative Code. Required for every employee subject to Level 2 background screening under Ch. 408, Part II, Florida Statutes.

Exemption from Disqualification

If applicable, indicate the exemption. A copy of the exemption decision letter must be attached.

Electronic Documentation & Signature Authenticity Agreement

I understand that the Agency staff may use electronic signatures on all computer-generated documentation. An electronic signature will serve as authentication on patient record documents and other agency documents generated in the electronic system.

For the purpose of the computerized medical record and other documentation for agency purposes, I acknowledge the combined use of my Electronic Signature Passcode and Log In authentication password will serve as my legal signature. I understand that I will be required to update my password regularly for security purposes.

I understand that prior to exporting documentation to the agency server, I am required to review and authenticate, by use of electronic signature, my documentation on the field-based or office computer. I understand that I am responsible for the security and accuracy of information entered into my organization's WellSky application (or any HHSG-designated electronic record system), and as such, I will:

• Not share or otherwise compromise my electronic signature credentials (Log In authentication password or Electronic Signature Passcode).
• Exit the online application at the end of each working day or whenever the computer is not in my immediate possession.
• Not save my login password and Electronic Signature Passcode on the computer, but will enter them upon each access of the application.
• Review all of my documentation online prior to submitting to the agency server.

Confidentiality Statement

I have been formally instructed regarding Agency policy and procedures for maintaining the confidentiality of all information contained in client/personnel files and records, as well as any other proprietary information regarding the agency that is obtained verbally.

I understand that, except as needed to conduct business, client and/or personnel information/proprietary information may not be discussed with anyone, either inside or outside the Agency.

I understand that medical records will not be removed from the Agency office unless the client has signed a Release of Information Form, and the removal of such information is approved by the Agency Administrator and/or designee.

I understand that any breach of confidentiality may be grounds for immediate termination of employment.

Disclosure of Interests

The following questions help Governing Body members, Professional Advisory members, and staff determine the nature and extent of any outside interest that might involve a conflict of interest with the affairs of HHSG. Read each carefully; answer briefly in the space provided.

Glossary

Competitor: A person offering for sale or selling products and/or services in competition with HHSG.
Family: Spouse, parents, children, brothers, sisters.
Purchaser: Any person who buys, rents, or otherwise procures from HHSG.
Person: An individual, firm, partnership, trust, corporation, or other business entity.
Vendor: Any person who sells, rents, or furnishes supplies, equipment, real estate, credit, insurance, or services to HHSG.

1. Ownership, Entertainment, Gifts, Loans

2. Employment Status

3. Related Staff Members

Declaration

I have read and understand the policies and procedures for this Agency and have had the opportunity to have all my questions/concerns addressed to my complete satisfaction. I further acknowledge receipt of the Agency's Employee Handbook.

I agree to abide by and uphold all rules, conditions, policies, and procedures, and have been advised that failure to do so may result in termination of employment.

I also agree that as a requirement of employment, regardless of status (e.g., full-time, part-time, per diem, etc.), I will provide the Agency with a fourteen (14) day written notice of intent to terminate employment.

I have received orientation from the ADM and DON of the Agency and have signed my orientation receipt.

SMS & Email Notification Consent

SMS opt-in is optional. Email contact is part of standard hiring communication. Check the boxes that apply.

SMS opt-in (optional)

Your contact details

These prefill from DOC 02 Demographics. Edit only if different.

Independent Contractor Agreement

This Agreement is effective as of the date signed below, and is by and between Home Health Solutions Group, Inc., a Florida corporation ("Company"), and the undersigned Contractor. This document contains the full legal text of your independent contractor agreement. Read every section carefully before signing.

Recitals

WHEREAS, the Company is primarily involved in the business of providing Home Health Services to persons requiring these services; and

WHEREAS, the Company wishes to engage the Contractor and the Contractor wishes to be so engaged, to provide Home Health Services to persons designated by the Company, as an independent contractor, upon the terms and conditions contained below;

NOW, THEREFORE, in consideration of these premises, mutual promises, covenants, terms and conditions contained herein, and other good and valuable considerations, the receipt and sufficiency of which are acknowledged by the parties, the parties agree as follows:

1. Services

Contractor shall provide, directly to Home Health Services persons designated by the Company, services at such times and at such places as shall be agreed to between the Company and the Contractor. Contractor agrees that all patients are accepted for services only by the Company.

2. Compensation

The contractor shall be entitled to receive from the Company a payment with respect to each service provided by the Contractor to persons designated by the Company, which compensation is (and shall be paid) as set forth under Exhibit "A" labeled and attached hereto and initialed by the parties hereto. Contractor shall not be entitled to any other compensation, and Contractor shall not be entitled to receive any reimbursement for any costs or expenses incurred by the Contractor or bill patient if services are not paid by Company. In connection with services provided by the Contractor, the Contractor shall prepare and provide to the Company, as may be reasonably requested, all reasonable documentation of such services in order that the Company, or any other entity designated by the Company, may comply with appropriate Federal and state laws with respect to the reimbursement by the Company, or such other entity, of the payments by the Company to the Contractor as compensation herein.

3. Contractor's Representations

Contractor represents to the Company that Contractor is, and will continue to be during the term of this Agreement, duly licensed as necessary in the State of Florida to provide the services hereunder, and the execution of this Agreement by the Contractor does not conflict with any other agreement to which the Contractor is a party. Contractor also represents that Contractor will perform hereunder without negligence and in compliance with all applicable laws including, without limitation, professional regulations. Contractor will dress appropriately while providing services.

4. Insurance

Contractor shall be responsible for obtaining and maintaining appropriate levels of professional liability insurance to cover the Contractor's performance hereunder. Contractor is required to provide Company a valid Certificate of Insurance reflecting professional liability insurance coverage immediately upon the request of Company. In addition, Contractor is required to maintain automobile liability and personal injury protection insurance and shall provide proof of such insurance to the Company whenever requested. The Contractor is not covered by the Company Worker Compensation insurance. Contractor must immediately notify Company if the Contractor's professional liability, automobile or PIP insurance is terminated, expires or is reduced, whether such action was initiated by the insurance Company or the Contractor.

5. Term

This Agreement shall commence as of the date first written above and shall continue for successive one (1) year terms, unless sooner terminated as follows: (i) this Agreement may be terminated by either party hereto upon thirty (30) days' written notice prior to the commencement of the successive one (1) year period; (ii) this Agreement may be terminated by the Contractor if the Company fails to pay any compensation due to the Contractor hereunder within forty-five (45) days of the Company's receipt of written notice of demand for payment from the Contractor; (iii) this Agreement may be terminated by the Company at any time without notice in the event the Contractor breaches any covenant or representation under this Agreement; or (iv) this Agreement may be terminated at any time upon mutual written consent of the parties.

6. Independent Operation and Indemnity

The parties acknowledge that neither (I) the Contractor, nor (ii) the Company, or any of their affiliates (including, without limitation, principals, employees, agents and executive officers, if any), shall be deemed hereunder joint ventures, principals, partners, employees or agents of the other party hereto; provided all of the duties, obligations and responsibilities of the Contractor, and all activities with respect to the satisfaction of the foregoing, shall be conducted by the Contractor independent of the Company as an independent contractor. The Contractor shall indemnify and hold the Company harmless from any and all claims of every kind and description whatsoever asserted against the Company arising out of the performance by the Contractor of Contractor's duties, obligations and responsibilities hereunder.

Notwithstanding anything contained herein, the Contractor shall not be permitted to delegate any of the Contractor's duties hereunder to any employee, not employed by the contractor, and for which the company has not received a completed and updated personnel file. Notwithstanding anything contained herein, the Contractor shall not be permitted to delegate any of the Contractor's duties hereunder to any agent or other person without the written consent of the Company. The Contractor is not entitled to participate in any plans, arrangements or distributions of the Company in connection with any pension, stock, bonus, profit sharing or any other plans or benefits paid or made available to regular employees of the Company. Contractor shall have general control of Contractor's activities with the right to exercise independent good judgment as to the manner (but only as permitted hereunder) of servicing patients, customers and otherwise carrying out the provisions of this Agreement. In acting as an independent contractor hereunder, Contractor shall be required to make arrangements for insurance, licenses and permits and for the payment of income taxes and social security taxes with regard to any payments received by Contractor and Contractor's services.

7. Restrictive Covenant and Confidentiality

All statistical, financial and personal data relating to the patient which is confidential and which is clearly designated as such, will be kept in the strictest of confidence by Contractor and Company. Accordingly, Contractor agrees not to compete with Company for those patients and legal entities Contractor has serviced under this Agreement.

The Contractor acknowledges and agrees that information concerning the patients, suppliers, office files, procedures and policies, and other aspects of the business of the Company, is confidential, and in connection therewith, the contractor agrees not to use or disclose any such information at any time except as permitted under or as otherwise permitted in writing by the Company. The contractor complies with all state, local federal and accreditation laws and rules as applicable. The Contractor agrees to immediately surrender all such information in the possession or control of the Contractor, including all reproductions thereof, upon any termination of this Agreement.

The Contractor hereby agrees and acknowledges that (I) this Section and each of its provisions are reasonable as they relate to restrictions and limitations upon the Contractor, (ii) neither this Agreement nor this Section will operate as a bar to the Contractor's sole means of support, (iii) this Section may be enforced by the Company through use of an injunction or any other equitable remedy given the amount of damages to the Company for a breach of this Section, in addition to any other remedies the Company may have hereunder or under law, (iv) the Company shall be entitled to reimbursement from the Contractor for legal fees, costs and expenses incurred by the Company through all appeals, if any, to enforce this Section (v) this Section shall survive any termination of this Agreement; and (vi) if any provision of this Section is deemed unenforceable by a court of competent jurisdiction for whatever reason, such term shall be substituted with such term of immediately lesser duration or effect which shall be deemed enforceable.

8. Disclosure and Access

Contractor agrees and acknowledges that it will promptly notify Company, in writing, of any inquiries, investigations, complaints, and any disciplinary actions taken by any entity based on the Contractor's actions or inactions. Contractor hereby authorizes any entity regulating or supervising the Contractor to release to Company all information relating to such complaint or disciplinary action. Contractor also agrees to provide Company access, upon request, to the Contractor's books, documents, and records. Contractor also agrees to allow federal and state agents access to books and records to verify the costs and reasonableness of the services furnished.

9. Third Party Beneficiaries

This Agreement has been entered into solely for the benefit of the parties hereto and in no event whatsoever shall any other party or parties be deemed a third party beneficiary or beneficiaries of this Agreement.

10. Company Responsibilities Under This Contract

Both Company and Contractor agree that the Company has the following responsibilities under this contract:

1. Admitting clients for services/care and maintaining all records of visits within the company patient record.
2. Scheduling of delivery/visits.
3. Specifying types and time frames for Company required documentation to be completed and submitted to Company.
4. Providing Contractor review and agreeing to comply with the policies and procedures including personnel, specifically addressing Contractor's qualifications and job duties/responsibilities.
5. Client assessments, re-assessments, formulation and revision of service plans and discharge planning, visit schedule for Home Health Services visits. Overall responsibility for supervision of personnel. Contractor shall participate with Company in these activities as qualified and stipulated in Contractor's agreement.
6. The Company will make all payments to the contractor on a biweekly basis, Friday, if all documentation is in for those services specified and completed to agency policies and procedures, as per contract.
7. The Company will perform first on-site evaluation, 90-day and annual evaluations/competency of the contractor's staff performing services, in the home, for the Company. This will be done with a professional of the same discipline and the DON/designee provided by the Company and arranged with the contractor to be done at the time of the home visit of the contractor staff. The Company may also make unannounced visits to ensure that the agency care/services are being performed as per agency policies and procedures.

Contractor Responsibilities Under This Contract

Both the Company and the Contractor agree that the Contractor has the following responsibilities under this contract:

1. Contractor will provide to the agency all documentation of services/care performed no later than every other Wednesday by 5:00 PM for the preceding 2 weeks.
2. Follow scheduled visits and notify agency of any changes immediately.
3. Maintain and comply with all agency policy and procedures including, but not limited to, personnel qualifications, orientation, competencies, required backgrounds, and Medicare conditions of participation when applicable.
4. Under Company responsibilities, Contractor shall participate with the Company in these activities as qualified and stipulated in Contractor's agreement including but not limited to case conferences, participation in developing plans of care and QA.
5. Contractor will assist as per Company with evaluations/competency.
6. Contractor will provide agency with all specified personnel files as per agency policies and procedures. These must be reviewed and approved for completeness by the Company. Contractor must have completed agency orientation with agency policies and procedures before date of hire can be established and first case to be assigned.
7. Company is responsible for the following: client assessments, re-assessments, formulation and creation/revision of service plans and discharge planning, visit schedule for Home Health Services visits. Contractor shall participate with Company in these activities as qualified and stipulated in Contractor's agreement.
8. Will maintain all requirements as outlined in the Social Security Section 1861(w). The agency will run annually an OIG exclusion. Contractor may not be: denied Medicare or Medicaid enrollment; excluded or terminated from any federal health care program or Medicaid; had its Medicare or Medicaid billing privileges revoked; or denied from participating in any government program.

11. Miscellaneous

This Agreement shall be governed by Florida law, with the sole venue for any action, suit or proceeding arising hereunder to be Miami-Dade County, Florida. No amendment to or assignment of this Agreement will be valid unless in writing and signed by the parties signing below. This Agreement may not be waived unless such waiver is in writing and signed by the waiving party. Each party acknowledges having been represented by independent legal counsel in connection with this Agreement or having waived such right. This Agreement sets forth the entire agreement of the parties as to the subject hereto and supersedes any prior agreement. Each party will execute such reasonable documents and take such reasonable action as may be reasonably requested to give effect to this Agreement. All costs and expenses of the parties in connection with this Agreement shall be borne by each such party incurring such costs and expenses. This Agreement may be executed in any number of counterparts.

IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and year first above written.

Notification of Introductory Period

Per HHSG policy, the first 90 days of employment are considered an Introductory Period. During this time both the employee and HHSG evaluate fit, performance, and work expectations.

I, _______________________________, in accepting employment with the Agency accept and understand the first 90 days of employment will be considered my introductory period. If for any reason my employment is terminated during this period, I understand and accept this account will not be charged with any unemployment benefits I may be eligible to receive under the State Unemployment Compensation Law.

I also understand and accept that at the end of the 90 day period, I will receive a written evaluation of my work performance. Should the Agency fail to provide this written evaluation, it shall be understood and accepted by all involved that the introductory period will have been completed satisfactorily.

Hepatitis B Declaration Form

Required under OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030). Hepatitis B is a major infectious occupational hazard in healthcare. The critical risk is contact with blood or other body fluids.

Persons previously infected with Hepatitis B virus are immune to the disease. For persons who have not had the disease, the Hepatitis B vaccine will provide immunity. The vaccine is given in three separate doses, and failure to receive all doses may cause the vaccine to be ineffective. Clinical studies have shown that 85 to 96 percent of those vaccinated develop evidence of immunity. Periodic testing of vaccinated persons for antibody to Hepatitis B will confirm immune status.

I have read the above information and have received verbal and written instructions regarding the efficacy, risk, and complications of receiving the vaccine. Any questions I had have been answered. I acknowledge that I am aware of the availability of the Hepatitis B vaccine and the benefit that such vaccination provides in the prevention of infection with Hepatitis B virus.

Your Decision

Vaccination Dates (if accepting)

Tuberculosis (TB) Screening Questionnaire

Required for all healthcare personnel. A "Yes" answer to any question requires further evaluation and assessment by a qualified health care provider before patient contact.

Please answer each question

Direct Deposit Authorization

Direct deposit is the fastest and most secure way to receive your pay. If you prefer paper checks, you can skip this form.

Orientation Checklist — Pre-Acknowledgment

I. General Orientation

II. Clinical Orientation

III. Safety / Risk Management / Infection Control

Required Documents

You may upload your documents securely below, or skip this step if you prefer to bring them in person. We respect both choices — please read the information below before deciding.

Professional Credentials Checklist

Check each item you currently have. Missing credentials must be obtained before your first patient visit.

In-Service Certificates

Recommended source: www.rn.org

Documents to bring to your orientation

Use the checklist above to confirm which items you have ready. Bring originals to your in-person orientation appointment. HR will verify and return them to you the same day. Do not mail originals.

Final Review & Submit

Review the status of all your documents. Click any "Edit" link to return and make changes. When all required documents are signed, submit your complete packet.