24/7 Home Care Agency of NY, Inc does not discriminate because of age, sex, physical handicap, race, creed, sexual orientation and any other protected classification, or national origin.
This agency is an equal employment opportunity employer.
I affirm that the information in this application is complete and true. I understand that if employed, false statements will be a cause for dismissal
I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of being infected by bloodborne pathogens, including Human Immunodeficiency Virus (HIV) and Hepatitis B Virus (HBV).
This is to certify that I have been informed about the symptoms and the hazards associated with these viruses, as well as the modes of transmission of bloodborne pathogens. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. In addition, I have received information regarding the Hepatitis B (HBV) vaccine. Based on the training I have received, I am making an informed decision to accept the Hepatitis B(HBV) vaccine.
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 Hepatitis B vaccine, at no charge to myself. However, I decline 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 Hepatitis B vaccine, I can receive the vaccination series at no charge to me.
CHECK ONE: I DECLINE Hepatitis B vaccine inoculation:
I ACCEPT Hepatitis B vaccine inoculation.
The Personal Assistant (PA) agrees to:
24/7 HOMECARE AGENCY OF NY. INC. Consumer Directed Personal Assistant Program Agrees to:
ACKNOWLEDGMENT OF RECEIPT
I have received the Personal Assistant’s guide and I have chosen to participate in the CDPAS as a Personal Assistant. I understand that 24/7 Home Care Agency of NY, Inc is the 24/7 HomeCare and I am hired, supervised, scheduled and trained by the consumer and/or designated representative. I have received, read and understand my role and responsibilities as Personal Assistant working for a Consumer or his/her Designated Representative participating in the 24/7 HOMECARE AGENCY OF NY, INC. CDPAS Program.
I have had an opportunity to ask questions concerning my wage and benefit package.
I have received the copy of the CDPAS Handbook, Code of Conduct, Compliance Program, Paid Family Leave and Notice of Employee Rights (regarding sick leave), Equal Employment Opportunity Act, Wage Parity, Anti-Sexual Harrasment notice and Fair Labor Standards Act (FLSA) on the date listed below. I understand that this form will be retained in my personnel file.
I understand and agree that, in the event there is any dispute or claim arising out of or relating to this Agreement or the release of claims set forth above will be resolved exclusively through a final and binding arbitration on an individual basis only, and not in any form of class, collective, or private attorney general representative proceeding. I understand and agree that I am responsible to pay my own legal fees arising from these disputes. Further, to the fullest extent permitted by law, you agree that no class or colelctive actions can be asserted in arbitration or otherwise. All claims, whether in arbitration or otherwise, must be brought solely in your or the company's individual capacity, and not as a plaintiff or class member in any purported class or collective proceeding.
My signature on this document acknowledges that I understand the above Arbitration Policy and agree to abide by its conditions. I further agree that, in accordance with 24/7 Homecare's Arbitration Policy, that I will submit any dispute arising under or involving my employment with 24/7 HomeCare to binding arbitration within 6 months from the date the dispute first arose. I agree that arbitration shall be the exclusive forum for resolving all disputes arising out of or involving my employment with 24/7 HomeCare. I agree that I will be entitled to legal representation, at my own cost, during arbitration. I further understand that I will be responsible for half of the cost of the arbitrator and any incidental costs of arbitration.
I acknowledge that I have been provided with a copy of an 24/7 Home Care Agency of NY, Inc.
Notice of Privacy Practices that provides a description of protected information uses and disclosures, and that I have had an opportunity to ask questions about anything that I did not understand.
I have read all the above statements, and will comply with these requirements. I also understand that failure to abide by the rules stated above could be considered Medicaid Fraud and could subject me to investigation and possible criminal prosecution by the Office of the Attorney General Medicaid Fraud Control unit, and the Medicaid Inspector General.
This is to certify that I ,
This is to certify that I am in receipt of Corporate Compliance Training and Educational Materials from my Consumer enrolled in 24/7 HOMECARE AGENCY OF NY, INC. CDPAP pertaining to the Federal False Claims Act, New York False Claim Act, Whistleblower Protection and Identifying Fraud and Abuse Law, as well as where to report these issue should they be suspected or uncovered.
I have been informed regarding HIPAA Privacy Rules by as provided to me by 24/7 HOMECARE AGENCY OF NY, INC and I acknowledge compliance with these rules as per NYS mandate.
I understand that the major goal of the privacy rules is to assure that all of our consumers health information is properly protected, while allowing the flow of vital healthcare/clinical information to all employees participating in providing patient care/services. As such, we can provide and promote high quality, safe and effective homehealth care.
24/7 HOMECARE AGENCY OF NY, INC also protects the public's health and their well-being by implementing disciplinary action upon notifications on any HIPAA violations by our employees.
► START HERE:Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
I understand that failure to comply with these requirements will put me and the patient I care for at risk, and my employment with 24/7 HomeCare Agency of NY, Inc is conditional on meeting these requirements.
24/7 HomeCare Agency of NY, Inc
Doing Business As(DBA) name(s) :
2414 Ralph Avenue
Brooklyn, NY 11234
2414 Ralph Avenue
Brooklyn, NY 11234
Before a chance in pay rates (s), allowances claimed or payday
3.Employee,s rate(s) of pay foe each type of work or shift:
Tips per hour
Meals .per hour
7.Overtime Pay Rates(s) for each type of work or shift:
This must be at least 1 1/2 times the worker's weighted average of the multiple rates of pay for the week, with few exceptions. The weighted average is the total regular pay divided by the total hours worked in the week. The overtime rate may vary from week to week depending on how many hours you worked at each rate of pay. The overtime rate may vary from week to week.
On this day I have been notified of my pay rate, overtime rate (if eligible), allowances, and designated payday on the date given below. I told my employer what my primary language is.
Check one:I have been given this pay notice in English because it is my primary language.
The employee must receive a signed copy of this form. The employer must keep the original for 6 years.
Please complete the following
Dependent (s) Please list names:
I am waiving coverage due to:
My preference not to have coverage
Coverage under my spouse's/domestic partner's plan name of carrier:
Other coverage name of carrier:
By signing below, I certify that I have been given an opportunity to apply for coverage for myself and my eligible dependents, if any. I am declining enrollment as indicated above. I understand that I am declining enrollment for myself or my eligible dependents (including my spouse) because of other health insurance or group health plan coverage, I may be able to enroll myself and my eligible dependents in this plan if I lose, or my eligible dependents lose, eligibility for that other coverage.
I understand that I must request enrollment no more than 30 days after the date the other health plan coverage ends (or after the employer stops contributing toward the other coverage). If I do not do so, I will not be able to enroll until my employer's next annual open enrollment period.
In addition, I understand that if I have a newly eligible dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my eligible dependent(s). However, I must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.
I understand that in order to request special enrollment or obtain more information, I should contact my group administrator.
Complete the worksheet on page 3 before making any entries
I certify that I am entitled to the number of withholding allowances claimed on this certificate
I, , acknowledge that I will not be able to start working as a Personal Assistant for the CDPAP program until I am specifically informed by 24/7 Home Care Agency of NY, Inc. that I am able to begin working on the case. Any allowance to work, that does not come directly from 24/7 Home Care Agency of NY, Inc. , will be considered invalid. If I work under an invalid authorization I realize that I will not be able to be able to be paid by 24/7 Home Care Agency of NY, Inc. for the time that I worked. I understand that, generally, instructions to begin working as a Personal Assistant will be provided to me along with a caregiver code and an explanation of the process for for clocking in and out.
I have completed the required training time provided by 24/7 HOMECARE AGENCY OF NY, INC.. I understand the responsibilities of all involved parties and agree to abide by them
I have received training in the following areas:
Assessing my needs Recruitment and Hiring Contents of an Advertisement Screening Applicant, Conducting and Interview, Checking References
Back-up Assistants Conflict Resolution
Personal and Property, Safety, Training my Personal Assistant
I acknowledge that I will meet with and interview my employee’s according to guidelines provided through my training program. I understand that I am responsible for completing the requested paperwork.
This defines the conditions of employment.
You employ me, as a participant in the Consumer Directed Program. I understand that I am directly responsible to you and not to 24/7 HOMECARE AGENCY OF NY, INC.
I agree to work on the assigned days and times of my employment. I understand that I must contact you at least two hours before my assigned work in case of an illness or any other emergency.
I understand that I have to perform the tasks as listed on the care plan in a responsible, courteous, and prompt manner, and will be expected to respect your possessions, your lifestyle, and your home.
I understand that no confidential information is to be discussed or disclosed in any way without permission of
24/7 HOMECARE AGENCY OF NY, INC. or you the client.
I acknowledge that I have been provided with a copy of 24/7 HOMECARE AGENCY OF NY, INC. Notice of Privacy Practices that provides a description of protected information uses and disclosures, and that I have had an opportunity to ask questions about anything that I did not understand.
I have completed the required training required by 24/7 HomeCare Agency of NY , Inc. I understand the responsibilities of all involved partied and agree to abide by them.
I have received training in:
I understand that I will meet and interview my employee’s according to guidelines provided by my training program. I also Understand that I am responsible for the completion of all requested paperwork.