Temporary Fill-Ins, South

Transcription

1 Temporary Fill-Ins, South Serving Your Dental Staffing Needs Christine L. Kennedy P.O. Box Highlands Ranch, CO J (866) DDS-STAF (303) fax (303) agree to work in any Dental office, as referred by Temporary Fill-Ins South. 1. I understand I am responsible for ederal Taxes, State Taxes, and FICA payments, and any local fees or taxes that may apply. 2. I understand that I am not entitled to unemployment insurance or worker's compensation from Temporary Fill-Ins South. 3. I agree to consult the Doctor to whom I have been referred regarding any necessary tax forms to be completed in lieu of my temporary employment and as a representative of Temporary Fill-Ins South. 4. I understand Temporary Fill-Ins South will supply my time slips and that I am responsible to request said slips when needed. 5. I understand that I will receive my fees at the end of each day from the Doctor to whom I have been referred unless prior arrangements have been made. *hourly rate and payment of fee can be discussed with TFIS. 6. I agree to give Temporary Fill-Ins South a two-week notice in the event I choose to terminate my representation of Temporary Fill-Ins South. This notice applies to permanent placement also. 7. I agree to accept my temporary employment through Temporary Fill-Ins South only for any office or affiliate for which Temporary Fill-Ins and Temporary Fill-Ins South have sent me. 8. If an office requests my telephone number I will refer them to Temporary Fill-Ins South (in other words, your new telephone number is 866-DDS-STAF or ) 9. Temporary Fill-Ins South agrees to contact representative if there are any changes or additions to schedule in an office. 10. I have been informed that in the event a Doctor to whom I have been referred to by Temporary Fill-Ins South offers a permanent or temporary position I am obligated to notify Temporary Fill-Ins South for a period of twelve months. 11. Any office wishing to hire a Temporary Fill-Ins South temporary and placing him/her in any position in the office will be responsible to pay Temporary Fill-Ins South the current placement fee. 12. If for any reason the Dentist chooses not to pay the placement fee and I choose to accept employment, I am fully responsible to Temporary Fill-Ins South for the placement fee. 13. I will inform Temporary Fill-Ins South immediately concerning any permanent placement offers. 14. I understand Temporary Fill-Ins South will assist in any contract negotiations with any potential employer. 15. As a representative of Temporary Fill-Ins South, I agree to perform to the best of my abilities and represent Temporary Fill-Ins South in a professional manner. Temporary Fill-Ins South Representative

2 EDUCATION BACKGROUND High School Year Graduated College Associates / Bachelors EMPLOYMENT HISTORY DATE MONTH / YEAR NAME AND ADDRESS OF EMPLOYER PHONE SALARY REASON FOR LEAVING REFERENCES (Please list the names of three persons not related for which you have known for at least one year) NAME ADDRESS PHONE YEARS OCCUPATION Do you have any criminal history? YES / NO Explain Do you have any outstanding warrants? YES / NO Explain I verify that the facts contained in this application are true and complete to the best of my knowledge. I authorize investigation of all statements contained herein.

3 ere9k1porart TILL SOVVI, you can start Personal Information Name Address City State Zip SSN DOB Telephone( Cell / Pager( Position Days Available (Circle): MON TUE WED THURS FRI SAT Current Employer May we inquire of your current employer? Yes No Years of Experience Salary Desired Hobbies and Intrests Hygiene License # Expiration Nitrous Oxide Certified: Yes / No CPR: Yes / No Expiration Local Anesthesia Certified: Yes / No Are you comfortable with Perio Therapy? Yes / No Explain Temporary Fill-Ins South, Inc. - P.O. Box , Highlands Ranch, CO Ph: DDS-STAF Ph: Fax:

4 Health Practice Information Agreement This agreement entered upon this the day of 200 is by and between Christine L. Kennedy of Temporary Fill-Ins South (further referred to as TFIS) and between Temporary Fill-Ins South associate (further referred to as Associate). Temporary Fill-Ins South has the responsibility for safeguarding Protected Health Care Information (further referred to as PHI) of clients (dental office). PHI includes all health records, dental records and personal information of an individual in any form including paper, electronic, computer or verbal. The Associate agrees to not use or disclose PHI other than as permitted or required by this agreement or as required by law. Associate agrees to use appropriate safeguards to prevent use or disclosure of PHI beyond the terms of this agreement. Associate agrees to report TFIS any use or disclosures of the PHI not covered by this agreement of which the Associate becomes aware. Associate agrees to ensure that any agent, representative or employee of TFIS including a subcontractor, to whom it provides PHI from the Dental Health care practice, agrees to the same restrictions and conditions that apply through this agreement to Associate. Associate agrees to make PHI and related records obtained from the Dental Health Care Practice (further referred to as DHCP) available to the Department of Health and Human Services to determine the DHCP's compliance with the Privacy Role. The DHCP agrees to disclose PHI to Associate the minimum amount of PHI necessary for the Associates purposes. Except and otherwise limited in this agreement, Associate may use or disclose PHI to perform functions, activities, or services for, or on behalf of the DHCP, provided that such use or disclosure does not violate the privacy role. If Associate violates the basis of terms of this agreement, the DHCP will make reasonable attempts to resolve the violations. If a resolution is not feasible, the DHCP will report the violation to the Department of Health and Human Services. Upon Termination of this agreement, for any reason, the Associate shall return or destroy all PHI received from the DHCP. Associate shall retain no copies of DHCP. Associate is not to sell or share any information of the DHCP if any information is known concerning this practice please report it to the Department of Health and Human Services. Any ambiguity in this agreement shall be resolved to permit the DHCP to comply with the Privacy Role. Temporary Fill-Ins South Dental Associate Effective Temporary Fill-Ins South Christine L. Kennedy Effective

5 DENTISTS: Dental License Number Expiration Where did you attend dental school? Year of graduation When did you receive your Colorado Dental License? HYGIENISTS: Colorado Dental Hygiene License Number Expiration Where did you attend dental hygiene school? Year of graduation Are you comfortable performing Periodontal treatment? (deep scaling / root planning) YES Are you certified to administer local anesthetic? YES NO Are you certified to administer Nitrous Oxide? YES NO Are you CPR certified? YES NO of certification Have you had your Hepatitis B Vaccinations? YES NO NO ASSISTANTS: Are you X-Ray certified? YES NO of certification Can you take Alginate impressions and pour models? YES NO Have you been trained in OSHA standards and regulations pertaining to dental office procedures? YES NO Have you received your EDDA certification? YES NO Have you had your Hepatitis B Vaccinations? YES NO Are you CPR certified? YES NO of certification FRONT OFFICE: What dental computer programs are you familiar with? AUTHORIZATION: By signing below, I certify that the facts contained in this application are true and understand that, if employed, falsified statements on this application will be grounds for immediate termination. I authorize investigation of the above statements, references and employer information (current and previous) I have supplied on this application or during my interview. I authorize the references and employers listed above to give you and any and all information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws. (Revised )