Acknowledgement Form 1

ALL EMPLOYEE/CONTRACTORS SIGN OFFS

Employee Sign Off Regarding HIPAA Privacy

I have read and understand this policy on Protected Health Information (PHI) and security. I understand that should any situation arise where I breach patient privacy I will be disciplined up to and including termination.

Employee Sign Off Regarding HIPAA Privacy(Required)

Corporate Compliance Employee Sign Off

Our Agency is committed to providing the highest ethical health care and upholding conduct standards and corporate legal compliance. Our policies support a zero tolerance to any form of fraud or misconduct.

Corporate Compliance Employee Sign Off(Required)

Incident/Accidents Reporting Acknowledgement

I have been informed that I MUST report ALL incidents or accidents immediately to the supervisor or office.

Incident/Accidents Reporting Acknowledgement(Required)

Acknowledgement / Understanding of Zero Tolerance Sexual Abuse Policy

I acknowledge that I have read the sexual abuse policy and understand the organization will not tolerate abuse.

Acknowledgement / Understanding of Zero Tolerance Sexual Abuse Policy(Required)

Fraud/False Claims Laws / Whistleblower Protection Policy

I have received and reviewed the Agency policy on Fraud as part of my hire packet.

Fraud/False Claims Laws / Whistleblower Protection Policy(Required)

Employee/ Contractor Signature(Required)

Date(Required)