Employee Documents

General employment documents and forms:

• Employee Handbook 2019
• Request for Time Off (to be returned to your immediate supervisor upon completion)
• Release of Protected Health Information (PHI) for Other Purposes and Activities

 

Printable Chronic Care Management (CCM) forms:

• CCM Correctional Demo Insurance Sheet
• CCM Manual 2017
• CCM Opt-Out Form
• CCM Opt-Out & Opt-In Log Patient Forms for Clinic 2017
• CCM Phone Encounter
• CCM Time Log 2017
• Patient Consent for Chronic Care Services January 2016

 

The following forms will need to be printed, filled out, and returned to Suzanne Bolton:

• Compliance/HIPAA Acknowledgement Form
• Notice of Privacy Practices Acknowledgement Form

 

The following forms will need to be printed, filled out, and returned to Susan Hall, Human Resources:

• 2017 A-4 Form
• 2017 W-4 Form
• 2017 I-9 Form 2016-2019
• BCBS Dental Ins Application 2016
• BCBS Health Ins Application 2016
• Direct Deposit Agreement Form 2017
• 2017 Employment Application
• 2017 401k Auto Enrollment Notice
• ADA Acknowledgement Form
• 401k Auto Enrollment Acknowledgement Form
• Code of Conduct
• PCI DSS Acknowledgement Form
• PCI DSS Payment Card Industry Data Security Standards
• Coding and Billing Policies and Procedures