Anita Anim

• To: Care Providers
• From: EldersChoice Human Resources
• Re: Application for Registration
• Thank you for your interest in EldersChoice. The pages that follow are an application to be registered as a care provider with EldersChoice in Connecticut, Maryland and Virginia. We are in the business to arrange for the placement of full-time live-in home-care professionals (Care Providers) who work as independent contractors to provide homecare for individuals who need support personal care, homemaking and companionship in their place of residence or other living environment. EldersChoice only places full-time live-in care providers.
• Care Providers must meet EldersChoice standards. This includes being legal to work in the United States, have training and experience, and be healthy. The Application includes a checklist of all the information we need from you. An interview is required after a file is complete. After you complete and sign our Referral Agreement, and you are eligible for referral.
• Being registered means that you want EldersChoice to present possible client opportunities (cases) to you. You have the right to pursue or decline any client opportunity. You do not have to use EldersChoice to find clients. A Care Provider can accept a placement from any person and use other agencies to find clients.
• As the Care Provider, you are paid directly by the client. You never pay EldersChoice for placement services. Care Providers are independent contractors and not employees of EldersChoice for all purposes, including federal, state, and local taxes. The services you provide, hours, and pay are entirely between you and the referred Client. Any changes to fees, work schedule, and time off is between you and the referred Client. EldersChoice has no right to tell the client what to do, terminate, interfere, or impose any terms or conditions on your relationship with the client.
• EldersChoice is an equal opportunity organization. EldersChoice does not discriminate in referrals on the basis of race, sex, color or national origin, age, ancestry, religious creed, sexual orientation, and handicap or disability.
• PLEASE FILL OUT THE APPLICATION AND FOLLOW THE MAILING or FAX INSTRUCTIONS ON THE NEXT PAGE
• May 2023

• Please send COPIES of the following to EldersChoice:
• Care Provider Registration Form
• United States Passport, Naturalization Certificate, Permanent Resident Card, or Work Authorization.
• Social Security Card
• Proof of Training or License (CNA/HHA/PCA/STNA)
• Certification of Elder Abuse Training [CONNECTICUT only.] Free online at https://portal.ct.gov/dss/learncenter/elderabuse/mand/story_html5.html
• Driver's license or Non-Driver's picture Identification
• Health form with results of a physical performed within the last 24 months signed and stamped by your doctor or other licensed health professional. You do not have to use EldersChoice form if you already have one from your doctor.
• Copy of your Covid-19 vaccination card
• PPD Form showing proof of a negative two step Mantoux test or chest x-ray within the last two years. You do not have to use EldersChoice form if you already have one from your doctor.
• Authorizations for criminal background check in Connecticut & Maryland
• Work Reference sheets provided. SIGN ONLY. EldersChoice will use the space to document your work from two previous employers. EldersChoice only accepts references from hospitals, nursing homes, rehabilitation facilities, nursing and hospice agencies, other home care agencies, group homes or private cases.
• INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED & DESTROYED IN 30 DAYS
• Please Mail or Fax this Registration Application to ONE of the Locations Below.
• EldersChoice of Maryland, LLC
• 3681 Ashley Way
• Owings Mills, MD 21117-1435
• Fax: 410-363-6795
• EldersChoice of Connecticut, LLC
• P.O. Box 370361
• West Hartford, CT 06137-0361
• Fax: 860.523.8400
• May 2023

• Name: ____________________________________________
• Current Address:___________________________________________
• Years at this Address: ____ Prior Address: ____________________________
• Phone: (____) _______________ Cell Phone: (____) _______________ Home
• Date of Birth (mm/dd/yyyy): _____________ Email Address: __________________________
• Social Security Number: __________________ EIN Number: __________________________
• (Please provide copy of Social Security Card)
• Passport, Green card or Long Term Visa Number: __________________________
• (Please provide copy of passport or Green Card)
• Work Permit? Yes No Expires: ______________ (Please provide copy of Work Permit)
• Driver’s License: State: ______ Number: __________________________
• (Please provide copy of Driver’s License)
• RECENT WORK EXPERIENCE/REFERENCES:
• 1. Name of Client or Business:___________________________________________
• Address:________________________________________________________
• State and Zip Code: ___________________________ Telephone:________________
• How long did you work there?___________________________
• 2. Name of Client or Business:___________________________________________
• PROFESSIONAL EDUCATION AND TRAINING:
• High School: __________________________ City/State: ________________________
• Dates Attended: __________________________
• College: __________________________ City/State: ________________________
• Dates Attended: __________________________ Degree Earned: __________________
• May 2023

• Trade School/Other: _______ __________________ City/State: ________________________
• Dates Attended: __________________________ Degree Earned: __________________
• TRAINING OR LICENSE
• (Please provide copy of Graduation Certificate or License):
• CNA Date Earned ________ State ____
• HHA Date Earned ________ State ____
• Other _______ Date Earned ________ State ____
• Special skills or training: ____________________________________________
• Date you are available to start work __________________________
• Range of fees you charge: from $ _________ per day – up to – $ __________ per day
• Are you registered with other home care agencies? Yes No
• Agency Names: ____________________________________________
• Locations you want to work? (check all that apply) CT MD VA
• Any restrictions on what you can do? ____________________________________________
• Other information about the kinds of clients you are seeking (e.g., no family living in home): __________
• Live in House with Pets? Yes No Live with client and family members? Yes No
• Live-in house with smoker? Yes No
• I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatements of fact, I am subject to disqualification, dismissal, or other action pursuant to employment agency policy and procedure, and subject to criminal penalties as prescribed by law. I understand that I am responsible for keeping EldersChoice informed of any changes to my registration information. I also authorize EldersChoice to verify the information contained in this document including, but not limited, to contacting previous employers/clients and references. I authorize all persons and companies listed herein to disclose any information concerning my background, and hereby release such parties from any liability or damages resulting from providing such information.
• Signature: ____________________________________________ Date: _____________
• Printed Name: ____________________________________________
• May 2023

• [You can use your own form]
• HEALTH HISTORY (the top portion to be completed by Care Provider)
• Have you ever had any of the following?
• Yes No Diabetes Yes No Shortness of Breath Yes No Hospitalized
• Yes No Heart Disease Yes No Epilepsy/Seizures Yes No Mental Disorder
• Yes No Hepatitis A Yes No Hepatitis B Yes No Asthma
• Yes No Stroke Yes No Back/Spinal Problems Yes No Salmonella
• Yes No Shigella Yes No COVID-19 Yes No HIV
• If you answered YES to ANY of the questions about, please explain: ________________
• Do you have any other conditions which might cause risk to a client or could potentially interfere with the performance of one’s duties, including the habituation of alcohol or current addiction to depressants, stimulants, narcotics, or any other substances? NO YES Please explain ____________________________________________
• I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatements of fact, I am subject to disqualification, dismissal, or other action pursuant to employment agency policy and procedure, and subject to criminal penalties as prescribed by law.
• __________________________________________ __________________
• Care Provider Signature Date
• CARE PROVIDER HEALTH EXAMINATION
• TO BE COMPLETED, SIGNED, DATED AND STAMPED BY PHYSICIAN
• Blood Pressure________ T______ P______ R______ Height_____ Weight_____
• Ears _____ Abdomen _____ Hernia _____ GI History________________________
• Eyes _____ Skin _____ Heart _____ GU History __________________________
• Nose_____ Throat _____ Lungs_____ Extremities __________________________
• Patient is found to be in good health without evidence of communicable disease or work restrictions except as noted: ____________________________________________.
• __________________________________________
• __________________________________________ _____________
• Physician/PA/APRN/Nurse Practitioner Date
• May 2023

• [You can use your own form]
• All Newly Registered Care Providers MUST Have Proof of a Negative 2 Step PPD or Chest X-Ray
• Section I: [To be completed by Care Provider]
• Last (Surname)Name: __________________________ First Name: __________________________ MI: ______
• Social Security Number:________________________ Telephone: __________________________
• Section II: [To be completed by Health Care Professional]
• __________________________________________
• Provider Name and Title
• Provider Address
• Tuberculosis Screening (PPD) – Step 1 Tuberculosis Screening (PPD) – Step 2
• Date Given: ________ Time: ________ Date Given: ________ Time: ________
• Manufacturer: __________________________ Manufacturer: __________________________
• Lot: ________ Exp. Date: ________ Lot: ________ Exp. Date: ________
• Dosage: ________ Route: ________ Dosage: ________ Route: ________
• Arm: (circle one) L R Arm: (circle one) L R
• Signature: __________________________ Signature: __________________________
• Section III: [To be completed if 10mm or greater]
• 1. Attach copy of Chest X-ray report.
• 2. Is patient free of infectious Tuberculosis Disease? Y N
• 3. Was patient referred for treatment? Y N
• If Yes, When, Where and What is treatment __________________________
• 4. Was BCG given? Y N
• If Yes, when was it given? __________________________
• May 2023

• PLEASE ONLY SIGN AND DATE THIS FORM
• Care Provider Name:___________________________________________
• SSN:_______-_____-_______
• Employer/Client: ___________________________________________
• Job Description:___________________________________________
• Please list start and end date of employment: _____________to_____________
• Is __________________________ eligible for rehire? Yes No
• Comments if possible:
• __________________________________________
• I give EldersChoice permission to check my previous employment references.
• __________________________________________ __________________
• Signature of Care Provider Date
• Print Name __________________________________________
• May 2023

• In accordance with Chapter 400o, Section 20-678 of the Connecticut General Statutes, Homemaker and Companion Agencies are required to conduct a comprehensive background check of all care providers. In addition, prospective care providers are required to reply to the following questions:
• 1. Have you ever been convicted of a crime involving violence or dishonesty in a state court or federal court in any state? Yes No
• 2. Have you ever been subject to any decision imposing disciplinary action by a licensing agency in any state, the District of Columbia, a United States possession or territory or a foreign jurisdiction? Yes No
• EldersChoice will not refer any care provider who has a history of elder abuse or criminal background.
• I hereby certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. Further, I authorize EldersChoice of Connecticut, LLC to conduct a comprehensive background check. I understand that if I knowingly make any misstatements of fact, I am subject to disqualification and dismissal and to such other penalties as may be prescribed by law or EldersChoice policy and procedure.
• As sworn by me this __________ day of __________________________ 20 ____
• __________________________________________ __________________
• Signature of Care Provider Print Name
• Signature of Witness Print Name
• May 2023

• In accordance with Health - General Article Title 19, Subtitle 4B, Article 03(c) under the Annotated Code of Maryland, EldersChoice is required to perform a state criminal history records check or a private agency background check.
• EldersChoice will neither refer nor contract with an individual who has a history of elder abuse or criminal background.
• In signing below, you are attesting that you have not been convicted of any crime in your lifetime. In addition, your signature below serves as your permission to submit your name to be submitted for a State criminal history records check or a private agency background check.
• __________________________________________ __________________
• Signature Date
• May 2023

PATIENT CARE ASSISTANT CERTIFICATE

• Certified Job Title, Company Name - Timeframe