Who is in need of care?

Infant (age 0 – 2)

Child (age 3 – 18)

Adult female (age 19 – 64)

Adult male (age 19 – 64)

Senior (age 65 +)

How will we be able to contact you?

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Where will the patient need to receive home care?

(We provide care in the home, nursing facilities, and hospitals.)

Nassau

Suffolk

Queens

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Does the patient need care for any of the following?

Check all that apply

Diabetes Alzheimer’s Disease/Dementia Depression
Heart Disease Stroke Kidney Disease
High Blood Pressure Knee/Hip Replacement Cancer
Accident (an injury)

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What type of health insurance does the
patient have or is eligible for?

Check all that apply

Private insurance (e.g., GHI-HIP, Aetna, BlueCross BlueShield)

Out of pocket (private pay)

Medicaid

Medicare

None

NOT SURE

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How quickly will the care need to begin?

Immediately (within 24 – 48 hours)

This Week

This Month

NOT SURE

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General Information




A conviction will not necessarily disqualify an applicant from employment.

Certification
Certificate

Education and Training
School Name, City, State
School Name, City, State
School Name, City, State
School Name, City, State
Employment History

Please list most recent employer first. Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here.

Employer













Knowledge, Skills, and Abilities

List skills you possess and believe are pertinent to the position you seek, such as computer skills, fluency in language, supervisory skills. 


References

List persons who know your work professionally, excluding supervisors

Reference




No family, please.

(Rounded to the nearest year)

Work Preferences













I certify that answers given herein are true and complete to the best of my knowledge.

I understand that, in the event of employment, false or misleading information given in my application or interview may result in discharge.

I authorize investigation of all references and statements contained in the application for employment as may be necessary in arriving at an employment decision.

I understand that after meeting all other job prerequisites, and after I am offered a job, employment will be contingent upon satisfactory outcome of a medical examination and criminal background check.

I understand that my employment may be terminated at any time, without liability to me for wages and salary except as have been by me at the date of such termination.


Access Home Care an approved provider of the NY State Department of Health Traumatic Brain Injury and Nursing Home Transition Diversion Waiver.

  © 2011 Access Home Care Inc. | 3100 Veterans Memorial Highway | Bohemia | NY 11716 | 631-476-3600