Application - A&T Healthcare

Name(Required)

First Middle Initial Last

Last 4 Digits of SSN

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone(Required)

Mobile(Required)

Email Address(Required)

Emergency Contact Name(Required)

Emergency Contact Phone(Required)

Are you authorized to work in the US?(Required)

Yes

Are you HHA Certified?(Required)

Yes

Are you PCA Certified?(Required)

Yes

If you are not certified, are you interested in the training course?(Required)

Yes

I am available to work in the following areas:(Required)

Sullivan

Brooklyn

Queens

Manhattan

Staten Island

Bronx

Nassau County

Suffolk County

Rockland County

Rockaway

Orange County

Westchester County

I am able to speak the following languages:(Required)

English

Arabic

Bilingual

Chinese

French

Russian

Creole

Cantonese

Spanish

I can start working:(Required)

Immediately

Or on the following start date

Start Date

MM slash DD slash YYYY

Can you work live-in cases?

Yes

Have you received the Covid 19 vaccination

Dose

Are you willing to work with Covid positive patients?

Yes

Can you work on weekends?

Yes

By signing this form, I authorize A & T Healthcare of New York to send text messages to my cell phone to alert me about available case opportunities, Timesheet links, HR matters, Compliance matters or any other company news related messages. I understand that standard text messaging, data and phone rates may apply to any messages received from A & T Healthcare and that A & T Healthcare is not responsible for payment of those fees. I understand that I may remove this permission in writing at any time. I further agree that in the event my cell phone number changes, I will inform HR department accordingly.

Text Messages(Required)

I accept and DO want to receive text messages

I decline and DO NOT want to receive text messages

Cell Phone

Is this your primary phone?

Yes

By signing this form, I authorize A & T Healthcare of New York to send e-mails to alert me about available scheduling opportunities, Timesheet links, HR matters, Compliance matters or any other company news related messages. I understand that I may remove this permission in writing at any time. I further agree that in the event my e-mail address changes, I will inform HR department accordingly. I further agree that in the event my cell phone number changes, I will inform HR department accordingly.

Email Messages(Required)

I accept and DO want to receive emails

I decline and DO NOT want to receive emails

Is this your primary email?

Yes

I understand A & T Healthcare may offer short hour assignments and will make every effort to offer additional short hour cases to provide caregivers with total hours of work at caregiver’s request. In order for HHAs/PCAs to remain in ACTIVE status, caregivers must work/provide service hours to patients continuously during employment. HHAs/PCAs who do not provide service hours for a period of 120 days may be terminated. I further understand that declining/refusing more than three cases in a 30-day period may result in disciplinary action up to and including discharge. It is the responsibility of the HHA/PCA to communicate with the agency regarding changes to availability and to request cases to ensure compliance. I am aware that I cannot and will not work for other Licensed or Certified Home Care Agencies or any other organization during the hours that I am assigned to provide home health aide services to a patient of A & T Healthcare of New York.

I have read, understand, and agree to abide by the complete agreement.

E-Signature(Required)

By signing above I acknowledge that all the information provided above is true and accurate. I further acknowledge my understanding of the terms and conditions listed above.

Date(Required)

MM slash DD slash YYYY

ID Front