Job Description

Job Title: Personal Care Aide (PCA) / Caregiver

Classification: 1099 Independent Contractor

Reports To: RN Supervisor (Clinical Oversight)

Position Summary

The Personal Care Aide (PCA) / Caregiver functions as an independent contractor providing non-medical, in-home personal care and support services to clients of allheart Senior Care of Arkansas. Services are delivered in accordance with the client’s authorized care plan, Arkansas Department of Health (ADH) guidelines, applicable Medicaid and Veterans Affairs (VA) regulations, and agency standards.

Essential Duties & Responsibilities

Independent Contractors may perform the following authorized non-medical services, as outlined in the client’s care plan:

Assist with Activities of Daily Living (ADLs), including:
- Bathing, grooming, oral hygiene, and dressing
- Toileting and incontinence care
- Ambulation, positioning, and transfers
Provide assistance to promote client safety, comfort, and independence to stay in their home
Perform homemaker and light housekeeping services, limited to:
- Laundry related to the client
- Meal preparation per care plan
- Cleaning of areas used by the client during care
Observation and reporting of changes in client condition, behavior, or environment
Timely and accurate documentation using the agency’s electronic visit verification (EVV) and documentation systems (AxisCare)
Maintain confidentiality and professional boundaries in compliance with HIPAA and agency policies

Scope of Non-Medical Services

Services provided under this role are strictly non-medical and do not include:

Medication administration or management, including injections, dosage changes
Skilled nursing services or medical treatments
Medical decision-making
Invasive procedures or wound care
Diagnosis of illness or condition

Caregivers must operate only within the scope authorized by Arkansas Department of Health regulations, payer guidelines, and the individual client care plan. Performing tasks outside this scope is strictly prohibited.

Qualifications

To qualify as a 1099 Independent Contractor PCA / Caregiver, individuals must:

Possess a CNA license/PCA certificate
Completion of 40-hours aide training course

Independent Contractor Requirements

Successfully pass required state and federal background checks, including:
- Arkansas State Police criminal background check
- Adult Maltreatment Central Registry check
- Child Maltreatment Central Registry check
Possess the physical ability to perform essential care duties
Be able to read, write, and communicate effectively
Have access to a smartphone or electronic device capable of EVV and documentation
Agree to comply with all agency policies, care plans, and regulatory requirements
Meet 12-hours of annual continuing education requirements
Secure reliable transportation to assigned client locations

Professional & Compliance Expectations

Perform services in a professional, ethical, and respectful manner
Maintain punctuality and consistent communication regarding assignments
Accurately document all services rendered
Immediately report incidents, injuries, or concerns according to agency protocol
Adhere to all applicable ADH, Medicaid, and VA regulations

Name(Required)

First Initial Last

Form

W-9

(Rev. March 2024)

Department of the Treasury
Internal Revenue Service

Request for Taxpayer
Identification Number and Certification

Go to www.irs.gov/FormW9 for instructions and the latest information.

Give form to the
requester. Do not
send to the IRS.

Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below.

1 Name of entity/individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner’s name on line 1, and enter the business/disregarded entity’s name on line 2.)(Required)

2 Business name/disregarded entity name, if different from above.

3a

Check the appropriate box for federal tax classification of the entity/individual whose name is entered on line 1. Check only one of the following seven boxes.

Federal tax classification

C Corporation

Federal tax classification

C Corporation

Federal tax classification

S Corporation

Federal tax classification

Partnership

Federal tax classification

Trust/Estate

Federal tax classification

LLC.

LLC Enter the tax classification (C = C corporation, S = S corporation, P = Partnership)

Note: Check the “LLC” box above and, in the entry space, enter the appropriate code (C, S, or P) for the tax classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate box for the tax classification of its owner.

Federal tax classification

Other

Other (see instructions)

3b If on line 3a you checked

Foreign partners, owners, or beneficiaries.

If on line 3a you checked “Partnership” or “Trust/estate,” or checked “LLC” and entered “P” as its tax classification, and you are providing this form to a partnership, trust, or estate in which you have an ownership interest, check this box if you have any foreign partners, owners, or beneficiaries.

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):

Exempt payee code (if any)

Exemption from Foreign Account Tax Compliance Act (FATCA) reporting code (if any)

(Applies to accounts maintained outside the United States.)

5 Address (number, street, and apt. or suite no.). See instructions.

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I

Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. See also What Name and Number To Give the Requester for guidelines on whose number to enter.

Social security number

Or

Employer identification number

Part II

Certification

Under penalties of perjury, I certify that:

The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
I am a U.S. citizen or other U.S. person (defined below); and
The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and, generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Signature(Required)

Date(Required)

General Instructions

Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.

What’s New

Line 3a has been modified to clarify how a disregarded entity completes this line. An LLC that is a disregarded entity should check the appropriate box for the tax classification of its owner. Otherwise, it should check the “LLC” box and enter its appropriate tax classification.

New line 3b has been added to this form. A flow-through entity is required to complete this line to indicate that it has direct or indirect foreign partners, owners, or beneficiaries when it provides the Form W-9 to another flow-through entity in which it has an ownership interest. This change is intended to provide a flow-through entity with information regarding the status of its indirect foreign partners, owners, or beneficiaries, so that it can satisfy any applicable reporting requirements. For example, a partnership that has any indirect foreign partners may be required to complete Schedules K-2 and K-3. See the Partnership Instructions for Schedules K-2 and K-3 (Form 1065).

Purpose of Form

An individual or entity (Form W-9 requester) who is required to file an information return with the IRS is giving you this form because they

FBI Criminal Record:

Fingerprints submitted with this application will be used to check FBI criminal records.

NOTIFICATION

This Notification Should Be Detached and Retained by Applicant

Fingerprints Submitted With This Application Will Be Used to Check FBI Criminal Records

NOTIFICATIONS FORM

To obtain a Copy of your FBI Criminal Record: Procedures for obtaining a copy of FBI criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.30 through 16.33 or go to the FBI website at http://www.fbi.gov/about-us/cjis/background-checks .

Changes, Corrections, or Updating of Federal Criminal Record: Procedures for obtaining a change, correction, or updating of an FBI criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34 or go to the FBI website at http://www.fbi.gov/about-us/cjis/background-checks .

If, after viewing his/her identification record, the subject thereof believes that it is incorrect or incomplete in any respect and wish changes, corrections, or updating of the alleged deficiency, he/she should make application directly to the agency which contributed the questioned information. The subject of a record may also direct his/her challenge as to the accuracy or completeness of any entry on his/her record to the FBI, Criminal Justice Information Service (CJIS) Division, and ATTN: SCU, Mod. D2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will then forward the challenge to the agency which submitted the data requesting the agency to verify or correct the challenged entry. Upon the receipt of an official communication directly from the agency which contributed the original information, the FBI CJIS Division will make any changes necessary in accordance with the information supplied by that agency.

Appeal of Determination: If your determination is based on an error such as wrong person, birth date, etc., please contact Health Facility Services Criminal History determination section at 501-661-2201. You may appeal a determination error within sixty (60) days by submitting a written request to: Health Facility Services Criminal History Appeals, 5800 W. 10th Street, #400, Little Rock AR 72204. Include your contact information and a description of the error.

Arkansas Code §A.C.A. 20-38-101

AR920130Z

Health Facility Services Background Check Application (Digital Prints)

Facility ID Number 799

Please enter a number greater than or equal to 0.

#7798005

Facility Name

Facility Phone

Address

Street Address Address Line 2 City State ZIP Code

Select Job Title

First ChoiceCNA, PCA, PERSONAL CARE AID PROVIDING CARE TO CLIENTS

OPERATOR/ ONLY FOR LICENSING PURPOSES

SELECT FACILITY TYPE

HOME HEALTH

HOSPICE

PRIVATE CARE

• ALL STATE AND FEDERAL BACKGROUND CHECKS MUST BE REQUESTED THRU ARKANSAS STATE POLICE CRIMINAL BACKGROUND CHECK SYSTEM.

THIS PAPERWORK MUST BE SCANNED & UPLOADED INTO ARKANSAS STATE POLICE CRIMINAL BACKGROUND CHECK SYSTEM WHEN YOU REQUEST A FEDERAL BACKGROUND CHECK. IF PAPERWORK IS INCOMPLETE, LETTER OF DETERMINATION WILL NOT BE PROCESSED.

FEDERAL FINGERPRINTS MAY ONLY BE REQUESTED IF THE APPLICANT HAS NOT LIVED CONTINUOUSLY IN ARKANSAS FOR THE LAST 5 YEARS.

APPLICANT: LAST NAME ON PAPERWORK MUST MATCH NAME FINGERPRINTS ARE SUBMITTED UNDER

Name(Required)

First Middle Last Maiden

Date of Birth(Required)

Social Security Number(Required)

Race(Required)

Sex(Required)

Drivers License(Required)

State of Issue(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

NAME, ADDRESS AND DATE OF BIRTH VERIFIED ON THE FOLLOWING GOVERNMENT ISSUED IDENTIFICATION DOCUMENTS

Document ID

Drivers License

Document ID

State ID Card

Other

Other ID

Document ID other

List

Other

Other ID

The qualified entity employer may receive copies of the state record check results. Any challenges to the accuracy of the state results should be directed first to the Arkansas State Police, (501) 618-8500, #1 State Police Plaza Drive, Little Rock, AR 72209.

I understand that my personal information and fingerprints submitted by agency are used to search against criminal identification records from both Arkansas Crime Information Center (ACIC) and Federal Bureau of Investigation (FBI). I hereby authorize the release of any records to the person or agency listed above.

I further understand ACIC and the FBI may also retain the submitted information and fingerprints as permitted by the Privacy Act of 1974, 5 USC § 552a, for routine uses beyond the principal purpose listed above.

Privacy Right Statement

Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application.

Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems, including civil, criminal, and latent fingerprint repositories, or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.

Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.

Signature(Required)

Date(Required)

Consent

(Initial inside each box)

I HEREBY GIVE MY CONSENT FOR THE ARKANSAS STATE POLICE AND THE FBI TO CONDUCT THE REQUIRED CRIMINAL RECORD CHECK ON MYSELF AND RELEASE ANY RESULTS TO THE LICENSING AUTHORITY AND THE STATE RESULTS TO THE QUALIFIED ENTITY

(Initial inside each box)

I RECEIVED WRITTEN DIRECTIONS FOR CHANGES/CORRECTING/UPDATING MY FBI CRIMINAL RECORD

(Initial inside each box)

I RECEIVED WRITTEN DIRECTIONS ON HOW TO OBTAIN A COPY OF MY FBI CRIMINAL RECORD

(Initial inside each box)

I RECEIVED WRITTEN DIRECTIONS ALONG WITH THE TIME FRAME EXPLAINING HOW TO APPEAL THE ACCURACY/DISPOSITION INFORMATION

STATEMENT OF OATH:

I STATE ON OATH THAT THE REPRESENTATIONS MADE HEREIN ARE TRUE AND CORRECT.

Signature(Required)

Date(Required)

Practitioner Identification Number Request

Division of Medical Services Medicaid Provider Enrollment Unit

Gainwell Technologies

P.O. Box 8105, Little Rock, AR 72203-8105

Practitioner Identification Number Request Form

Enrolment Type

Physician Assistant NV (Include a W9 for the Individual)

Non-Independent Licensed Clinician NW (Include license)

Certified Behavioural Analyst Paraprofessional BP

Certified Peer Recovery Support Specialist BH/SU RS

Pharmacist RX (Include license)

Or

Resident NU

QBHP NT

Community Support Staff CS

Personal Care Aide NT

Practitioner Name(Required)

First Last

NPI

Taxonomy Code

If Applicable

Social Security Number(Required)

Date of Birth(Required)

Physical Work Address(Required)

Street Address Address Line 2 City State ZIP Code

County

Physical Work Phone

Mail To Address(Required)

Street Address Address Line 2 City State ZIP Code

Individual Email Address

NU-Residents Only

Place of Residency

Effective Date of Residency

By signing, the applicant authorizes the Arkansas Department of Human Services to conduct a State and Federal background check. Results from the background check will determine the provider enrollment status with Arkansas Medicaid.

Signature(Required)

Date(Required)

Submission Notes: It is recommended and preferred to complete the online application through the Arkansas Medicaid Portal. The portal will guide you through the required information for the applied specialty. When submitting through the portal, the paper version is not required. RX & NW specialties will require a submitted license. NV specialty will require a W9 completed in the applicant's name and SSN, signed by the individual provider. NT Personal Care Aides — When submitting online, please select “Yes” to the question “Are you a personal care aide?” NPI should only be listed if registered to the applicant. If the NPI is listed, the taxonomy code is required to be listed.

Paper Submissions: If unable to submit through the preferred Arkansas Medicaid Portal, please type the information using this fillable PDF form when submitting paper applications. Mail the completed form to the address above.

Arkansas Department of Human Services Adult Maltreatment

Arkansas Department of Human Services

Request for Adult Maltreatment Registry Information

ADULT REGISTRY FORM

Applicant Legal Name(Required)

First Initial Last

Maiden or Other Names

Email(Required)

Social Security Number(Required)

Date of Birth(Required)

5 YEAR ADDRESS HISTORY

5 Years of Address History

Please provide your current address and enough past address history to cover the last 5 years.

Present Address

Present Address(Required)

Street Address City State ZIP Code

Dates (From/To) Address(Required)

Example:Jan 2005-Current

Past Address 1

Street Address City State ZIP Code

Dates (From/To) Address 1

Past Address 2

Street Address City State ZIP Code

Dates (From/To) Past Address 2

Past Address 3

Street Address City State ZIP Code

Dates (From/To) Past Address 3

Department of Human Services

I authorize

Department of Human Services/Adult Protective Services to release information from the Adult Maltreatment Central Registry in accordance with Ark. Code Ann. § 12-12-1717 to the following:

Agency Name(Required)

Contact Person(Required)

Mailing Address (Street or PO Box, City, State, Zip)(Required)

Agency Type

Volunteer

(no charge)

Non-Profit

(no charge)

State Agency

(no charge)

All Others

($10.00 Fee)

Address

Street Address City State ZIP Code

Certify

I further certify that the information provided on this form is true and correct.

Signature(Required)

Date(Required)

County(Required)

Arkansas Department of Human Services

Division of Child and Family Services

Request for Child Maltreatment Central Registry Check

GENERAL FORM

*MUST HAVE 5 YEARS OF ADDRESS HISTORY*

Reason for Registry Check: None of the above applies, but you would like a registry check.

GENERAL INFORMATION

Requesting Org: Hagood Holdings, LLC dba AHSCOAR

Representative Name: Andrea Scoles

Address: 322 S. State St Suite 101 Little Rock, AR, 72201

Representative Phone: (501) 772-6779

Representative Email: andrea@allheartar.com

APPLICANT INFORMATION

Applicant Legal Name(Required)

First Initial Last

Social Security Number(Required)

Maiden or Other Names(Required)

Race(Required)

Age(Required)

Phone(Required)

Date of Birth(Required)

5 Years of Address History

Please provide your current address and enough past address history to cover the last 5 years.

Present Address

Present Address(Required)

Street Address City State ZIP Code

Dates (From/To) Address(Required)

Past Address

Street Address City State ZIP Code

Dates (From/To) Past Address 1

Past Address 2

Street Address City State ZIP Code

Dates (From/To) Past Address 2

Past Address 3

Street Address City State ZIP Code

Dates (From/To) Past Address 3

Past Address 4

Street Address City State ZIP Code

Dates (From/To) Past Address 4

Is the applicant under 18 years old?(Required)

Yes

No

Parent/Legal Guardian Consent for Minor Applicant

I,(Required)

Applicant Name for Authorization Statement

Signature(Required)

Date(Required)

I authorize the Arkansas Child Maltreatment Registry to release any information their files may contain concerning me as an offender or of a true report of child maltreatment to the Arkansas Department of Education.

Physical Evaluation

This is an evaluation to determine ability to provide services for allheart Senior Care of Arkansas. If you are unable to perform any of the below tasks, you will need to follow up with your Primary Care Physician (PCP) for a release to provide services. By signing this form, you are accepting the responsibility to carry out the below tasks and/or obtain clearance from your PCP.

When was your last physical exam?(Required)

Date

Comments

Are you able to bend as if you are going to touch your toes?(Required)

Comments

Are you able to squat and raise back up without difficulty?(Required)

Comments

Are you able to lift up to 10lbs?(Required)

Comments

Are you able to extend your arms in a full range-of-motion?(Required)

Comments

Are you able to walk in place for one minute without difficulty?(Required)

Comments

Name(Required)

First Last

1099 Independent Contractor Agreement

This agreement is made between allheart Senior Care of Arkansas, of Little Rock, Pulaski County, referred to as the Company, and the Contractor identified below.

Please complete the Contractor Legal Name and County fields, then review and complete each section of this agreement.

Name(Required)

First Last

Address(Required)

County

Please write your agreed hourly rate

Recitals

A. Company owns and operates a Private Care Agency business, and Company desires to have the following services performed.

B. Contractor agrees to perform these services for Company under the terms and conditions set forth in this agreement.

In consideration of the matters described above, and of the mutual benefits and obligations set forth in this agreement, the parties agree as follows:

Section One: Description of Services

The work to be performed by the Contractor includes all services generally performed by Contractor in Contractor's usual line of business, including, but not limited to:

Bathing
Meal Preparation
Meal Consumption
Dressing
Personal Hygiene
Mobility / Ambulation
Incidental Housekeeping
Toileting
Laundry
Shopping / Errands

Section Two: Payment

Contractor may receive a minimum guarantee for a trial period. Company shall pay Contractor by commission, hourly rate, percentage of profit, unit or price of job, billing, or invoice, as applicable.

The minimum hourly rate for this agreement shall be entered below.

Hourly(Required)

Rate Per Hour

Minimum Hourly Rate(Required)

Please enter a number from 10 to 100.

Enter your agreed hourly rate

Section Three: Relationship of Parties

The parties intend that an independent contractor relationship be created by this contract. Company is interested only in the results to be achieved, and the control of the work will lie solely with the Contractor.

It is further understood that Contractor is free to contract for similar services to be performed for other entities while under contract with Company, including on the same day Contractor performs work for Company. Company shall not have priority on Contractor time and effort.

Contractor is not to be considered an agent or employee of Company for any purpose, and Contractor is not entitled to any benefits that Company provides to Company employees.

Company shall not cover Contractor with its policies or be liable for injuries incurred during work. This shall not bar negligence claims due to Company employees or facilities. Contractor shall hold Company harmless from actions brought by others, including taxes or otherwise, due to Contractor's work.

Contractor shall redo defective work and replace damaged materials at Contractor's own expense. If Contractor does not do this at Contractor's own expense, Company may deduct these costs from amounts due to Contractor.

Contractor need not meet a minimum quota. Contractor will work for the time needed to do the work. Specific work or schedule details, if applicable, should be entered below.

Work Details / Schedule Details

Varies based on authorization and client load

Company shall not provide a drawing account or advances. Contractor may stop work at any time, without liability to Company, unless the agreement is from competitive bidding. Company may stop work at any time, but shall be liable for work already done.

The Doctor and/or the Department of Human Services will decide time, place, manner, methods, and order of work, including the nature of the work. The Doctor and/or Department of Human Services may change hours at any given time that is deemed necessary.

Company shall not withhold any taxes from Contractor. Contractor shall be liable for Contractor's own withholding, Social Security, self-employment, and other applicable taxes.

Company shall not provide Contractor with, or reimburse Contractor for, hospital, medical, business liability or worker's compensation insurance, sick or vacation pay, a work vehicle, bonuses, gas allowances, uniforms, special clothing, pensions, or similar benefits. Contractor need not wear uniforms or special clothing while doing work for Company, except as local law may require.

The Contractor reports to the Company per Medicaid Rules and Regulation and Department of Human Services Rules and Regulations, and follows DHS guidelines for care.

If the Contractor requests, Company may provide instruction, briefings or orientations to Contractor. Contractor will select clients and hours to work through the Company job portal.

Company shall not supply Contractor with supplies needed for work. Contractor shall provide and maintain Contractor's own supplies and other items as needed. Contractor shall protect Contractor's property and shall take items when Contractor leaves. Contractor shall not have keys to Company facilities.

Section Four: Liability

The work to be performed under this contract will be performed entirely at Contractor's risk, and Contractor assumes all responsibility for the condition of tools and equipment used in the performance of this contract.

Contractor agrees to indemnify Company for all liability or loss arising in any way out of the performance of this agreement.

This Agreement and any attachments are the entire exclusive agreement between the Company and Contractor. Neither party shall assign it without written permission. It inures to the benefit of the successors and assigns of the parties.

The parties make no express or implied representations, warranties, promises, or guarantees about this Agreement, except as it expressly provides.

Section Five: Duration

Contractor may cancel this agreement on 10 days' written notice; otherwise, the agreement shall remain in force for a term of annually.

Agreement Acceptance and Signature

By completing the consent, signature, and date fields below, Contractor confirms that they have reviewed and accepted this 1099 Independent Contractor Agreement.

Signature(Required)

Caregiver Handbook

From

To

Agency or Facility 2

From

To

Agency or Facility 3

From

To

Supervisor Name & Contact Information:

Confirm

I confirm that I have a verifiable CNA, PCA or PCT license or certificate.

This field is hidden when viewing the form

For Office Use Only:

Approved

Not Approved

This field is hidden when viewing the form

Date

This field is hidden when viewing the form

Notes

Signature(Required)

Date(Required)

AxisCare Mobile Caregiver Guide

Once you have accessed the guide, complete the acknowledgement below.

Please download and review the AxisCare Mobile Caregiver Guide before continuing.

Download AxisCare Mobile Caregiver Guide

Company Handbook Receipt

Name(Required)

First Last

Acknowledgement of Receipt

I acknowledge that I have received access to the allheart Senior Care of Arkansas Company Handbook, either in paper form or electronically. I understand that it contains important information about the agency’s policies, procedures, benefits, and expectations.

By signing below, I confirm the following:(Required)

I understand it is my responsibility to read and become familiar with the policies contained in the Handbook.

Confirm(Required)

I understand it is my responsibility to read and become familiar with the policies contained in the Handbook.

Confirm(Required)

I understand that the Handbook is a guide and that the agency may modify, revoke, suspend, terminate, or change any or all policies at any time, with notice.

Confirm(Required)

I understand that my employment is at‑will, unless otherwise specified in a separate written agreement, meaning either I or the agency may terminate the employment relationship at any time, for any lawful reason.

If you need an accessible or translated copy of the Handbook, or have questions about any policy, contact your Care Coordinator or RN Supervisor immediately

Signature(Required)

Date(Required)

Printed Legal Name(Required)

First Initial Last

Contractor Onboarding

Job Description

Position Summary

Essential Duties & Responsibilities

Scope of Non-Medical Services

Qualifications

Independent Contractor Requirements

Professional & Compliance Expectations

Request for Taxpayer Identification Number and Certification

3a

General Instructions

What’s New

Purpose of Form

FBI Criminal Record:

NAME, ADDRESS AND DATE OF BIRTH VERIFIED ON THE FOLLOWING GOVERNMENT ISSUED IDENTIFICATION DOCUMENTS

Privacy Right Statement

Consent

STATEMENT OF OATH:

Practitioner Identification Number Request

By signing, the applicant authorizes the Arkansas Department of Human Services to conduct a State and Federal background check. Results from the background check will determine the provider enrollment status with Arkansas Medicaid.

Arkansas Department of Human Services Adult Maltreatment

ADULT REGISTRY FORM

5 YEAR ADDRESS HISTORY

Present Address

Past Address 1

Past Address 2

Past Address 3

Department of Human Services

I authorize

Agency Type

Certify

Present Address

Past Address

Past Address 2

Past Address 3

Past Address 4

CHILD INFORMATION

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

Child 7

Child 8

Child 9

Child 10

Child 11

Child 12

AUTHORIZATION STATEMENT

Baseline Individual TB Risk Assessment

Tuberculosis (TB) Screening

Physical Evaluation

1099 Independent Contractor Agreement

Recitals

Section One: Description of Services

Section Two: Payment

Section Three: Relationship of Parties

Section Four: Liability

Section Five: Duration

Agreement Acceptance and Signature

Caregiver Handbook

Confidentiality & HIPAA Acknowledgement

I acknowledge,

CNA/PCT/PCA Experience Training Waiver Request

Agency(s) or Facility(s) Where Experience Was Gained

AxisCare Mobile Caregiver Guide

Conflict of Interest Disclosure Form

Part 1: Disclosure Questions

Part 2: Acknowledgment

Company Handbook Receipt

Acknowledgement of Receipt

Request for Taxpayer
Identification Number and Certification