Personal Information

Driver Experience

Referral Information

Emergency Contact Information

Education

References

I authorize Loveall Management Group to contact the following references in relation to my character and qualifications. (References cannot be relatives. We prefer at least one past or current employer.)

Reference #1

Reference #2

I certify that the information provided is accurate and authorize Loveall Management Group to conduct reference checks.

CORI REQUEST FORM

Loveall Management Group is certified to obtain Criminal Offender Record Information (CORI) for individuals employed or volunteering with the elderly or disabled. By signing below, I authorize a CORI check for employment purposes.

Statement of Understanding

I understand that Loveall Management Group prohibits the contracting of individuals with histories of abuse, neglect, or mistreatment. I certify that I have no such history and will report any concerns of mistreatment or neglect through proper channels. Falsifying this document may result in termination of employment.

HIPAA CONFIDENTIALITY AGREEMENT

I, , acknowledge that I have been informed of my responsibilities under HIPAA regarding the protection of sensitive patient information and agree to abide by the following conditions:

1.Confidentiality of PHI
I understand that during my employment or association with Loveall Management Group, I may have access to confidential and sensitive information, including Protected Health Information (PHI). PHI includes, but is not limited to, patient medical records, treatment information, billing information, and any other health-related details that can identify a patient. I agree to maintain the confidentiality of all PHI and will not disclose any information unless required for the completion of my job duties, and only to authorized personnel with a legitimate "need to know."

2.Use and Disclosure of PHI
I will only use or disclose PHI in accordance with Loveall Management Group’s policies, procedures, and HIPAA guidelines. Any sharing of PHI outside of authorized personnel or purposes directly related to patient care, payment, or healthcare operations is strictly prohibited unless the patient has provided written consent.

3.Physical and Electronic Safeguards
I will protect PHI whether it is in physical or electronic form. This includes, but is not limited to, ensuring that: oPaper records are stored securely and are not left in public or unsecured areas. oElectronic records are accessed only through authorized devices and secured login credentials. oPHI is never shared through unsecured communication methods (such as personal email or unencrypted devices). oPHI is not visible or accessible during transportation in vehicles.

4.Access to PHI
I will not access or attempt to access any PHI that is not necessary for the completion of my assigned duties. Any unauthorized access or misuse of PHI is a violation of HIPAA and this confidentiality agreement.

5. Reporting Violations
If I become aware of any violations of HIPAA or unauthorized access, use, or 5.disclosure of PHI, I will report the incident immediately to my supervisor or the designated Privacy Officer at Loveall Management Group.

6.Consequences of Violation
I understand that violating this confidentiality agreement may result in disciplinary action, including termination of employment or contract, and may also lead to legal consequences in accordance with state and federal laws.


Acknowledgment
By signing this agreement, I confirm that I have received HIPAA training and understand the policies and procedures in place to protect PHI at Loveall Management Group. I further acknowledge that I understand the importance of protecting patient confidentiality and agree to comply with all applicable HIPAA regulations.