Healthcare Plus Online Application

  • Welcome to Healthcare Plus Online Application

    The information here will be used to autofill the paperback application. Please answer every question that shows an *

  • Employee Application

    This section will Fill out the majority of the general information needed.

  • Healthcare Plus is an equal opportunity employer. All applicants will be considered without regard to race, color, religion, creed, sex (including pregnancy, childbirth, or related medical conditions), gender identity and expression, sexual orientation, genetic information, national origin, ancestry, age (40 and over), disability, citizenship status, veteran status, military status or military obligations, or any other basis protected by applicable federal, state, or local government laws. Healthcare Plus also prohibits harassment of applicants based on any applicable legally protected category. It is also Healthcare Plus policy to comply with all
    deferral, state, and local government laws respecting consideration of unemployment status in making hiring decisions. Healthcare Plus maintains a smoke-free workplace in accordance with applicable law. Applicants are not obligated to disclose sealed or expunged records of convictions or arrest.

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  • Date of Birth*
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  • Today's Date *
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Format: (000) 000-0000.
  • Are you 18 years of age or older?*
  • Are you Currently authorized to work in the U.S.?*
  • Are you willing to be fingerprinted?*
  • Have you ever been dismissed from employment?*
  • Have you ever filed an application with us before?*
  • Have you ever been employed with us before?*
  • If selected for employment, can you provide a valid driver’s license and insurance?*
  • Did You Graduate?*

  • Refferences

    List at least three persons not related to you who can attest to your professional abilities and character.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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  • Staffing Questionnaire

    This section will Fill out your Staffing Questionnaire section of your application and help us find the clients that work best with your schedule
  • Rows
  • Do you have a pending/potential client?
  • Do you smoke?
  • Can you work for someone who smokes?
  • What languages do you speak?
  • Are you pet friendly?
  • Are you pet friendly? ( Select all that apply)
  • How would you like to be addressed?
  • Do you drive your own car, or use public transport?*
  • Have you ever received a dose of COVID-19 Vaccine?
  • Have you ever had a Positive test for COVID-19

  • Policy & Procedures

    This section will Fill out your Policy & Procedures section of your application
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  • Have you received a influenza vaccination*
  • Record of Influenza Vaccination Date:*
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  • Employee Handbook

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  • W-4 Forms

    This section will Fill out your W-4 section of your application. This will fill out the required parts, to fill out a comprehensive W-4 parts that might not be included here, please fill out a paper application at your nearest office.
  • Filing Taxes as*

  • Tax Withholding Estimator

    https://www.irs.gov/individuals/tax-withholding-estimator

  • IRS Worksheet

    https://www.irs.gov/pub/irs-pdf/fw4.pdf
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  • Step 4 (optional, Image above): Other Adjustments. Will you be Claiming other adjustments*
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  • Will you be filling out Section 2(b) (Image above, optional)*
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  • Will you be filling out Step 4(b) (Image above, optional)*
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  • I-9 & Background

    This section will Fill out your !-9 & Background section of your application. Most of the information in this part has already been filled out using your information from step 1
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  • I attest, under penalty of perjury, that I am (check one of the following boxes):*
  • Alien authorized to work until: (expiration date)*
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  • 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.   

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  • Gender*
  • Have you ever had an administrative finding of Abuse, Neglect or Theft?*
  • Have you ever been convicted of a criminal offense other than a minor traffic violation (do not include convictions that have been expunged, sealed or adjudicated  delinquent)*

  • I certify that the above is true and correct and give my consent for my name to appear on Department’s Health Care Worker Registry with the results of my criminal history records check.

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  • Home Care Aide (HCA) Driving History Questionnaire

    To help ensure the safety of our clients, we require all HCAs who will be driving clients to complete this questionnaire. Your honest responses will help us assess your eligibility to drive clients. Please note that providing inaccurate information may result in disciplinary action.
  • Driver’s License Date Issues*
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  • Driver’s License Expiration Date:
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  • Driving History

  • Have you been involved in any motor vehicle accidents in the past 5 years?*
  • Have you received any traffic citations or tickets in the past 5 years?*
  • Has your driver’s license ever been suspended or revoked?*
  • Have you ever been convicted of driving under the influence (DUI) or any other driving-related offenses?*
  • Do you have any current or pending traffic violations or legal actions related to driving?*

  • Commitment to Safe Driving

    By signing below, I agree to the following:

    ● I understand that I am responsible for maintaining a safe driving record and informing Healthcare Plus of any accidents, traffic citations, or legal actions related to driving that occur during my employment.
    ● I commit to providing Healthcare Plus a copy of my updated Driver’s License and proof of car insurance (if applicable).
    ● I certify that all information provided in this questionnaire is correct and complete to the best of my knowledge.

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  • Home Care Aide Transportation Agreement

    If HCA will NOT be driving, do not proceed; Complete “Do Not Drive” Waiver

    A Home Care Aide (HCA) driving for Healthcare Plus (Company) clients in any vehicle mustadhere to safe driving standards, including compliance with all traffic laws and DMV regulations. The use of hand-held devices for calls, texting, emailing, or browsing whiledriving is prohibited. HCAs may use their personal vehicles for Company business only if the vehicle is well-maintained and in safe condition. Any vehicle accident, damage, ortraffic violation must be reported to both the Case Supervisor and their insurance carrier within 24 hours. HCAs must notify their insurer of business use of their vehicle and ensurethe Company is not excluded from their personal insurance. HCAs are responsible for anydeductibles and must carry personal vehicle insurance meeting State requirements. HCA’s insurance is primary, with Company insurance as excess coverage. The Company will not reimburse the HCA for theft, road damage, collision, or any tickets and other violations.

    I agree to comply with the above policy and understand that any violation thereof may result in disciplinary action up to and including termination.

    I represent and warrant I will drive Company clients in my personalvehicle only if my vehicle is in safe operating condition and has received regular maintenance._______(Initials)

    I agree to carry personal vehicle insurance, covering liability and physical damage, in amounts sufficient to satisfy any requirementsunder state law._______(Initials)

    I accept the risks of driving for the Company and waive any claims against the Company forbodily injury or property damage related to such driving. I agree to indemnify, defend, and hold harmless the Company, its officers, employees, and successors from any related liability.

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  • Required Documents

    In this section you will submit the three required documents needed for your application. Please Submit documments on a solid background
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