welcome to the lifecare therapy team! sign...welcome to the lifecare therapy team! we are looking...

Welcome to the LifeCare Therapy Team! We are looking forward

to having you join a Company and a Team of therapists who are committed to providing the highest quality of outpatient physical, occupational and speech-language therapy services to the community that we serve. We look forward to working with you. Regulatory guidelines require certain information from you and also that you become familiar with LifeCare policies and procedures as they relate to the provision of therapy services and the management of the quality of services that we provide. The Sign-On Package is separated into two parts. Part I includes all regulatory information and Part II is specific to LifeCare policies and procedures. Reference Manuals and materials that you will need to review can be found on our website under “Therapist Education & Reference Materials”. Instructions to help with access and download of information are attached. Once your personnel file is complete, a one-to-one Orientation is scheduled with Connie Sakellaropoulos, OTR/L, Director of Clinical Services. This orientation normally takes about one hour of your time, is completed by phone, and reviews regulatory and LifeCare policies specific for your role.

Keep InTouch! We are here to help. Please contact us with any questions at 866-718-5757.

Extension Name Title

X 102 Elisha Becker Admissions Coordinator X 112 Alexia Larson Director of Operations / Personnel X 113 Connie Sakell, MOTR/L Director of Clinical Services

How to Work with LifeCare Forms LifeCare of Florida uses the Adobe PDF platform for all personnel documents. The PDF platform allows the documents to be opened, viewed and edited in any operating system, saved, and securely shared via e-‐mail. For successful operation of the form fields within the documents, it is essential that the free Adobe Reader Program be downloaded. While the forms will open in other PDF viewer programs (Reader & Preview), they may not function properly. Please follow these instructions.

Step 1: Download Adobe Acrobat Reader

https://get.adobe.com/reader/

Step 2: Access Paperwork Sign-on paperwork and reference materials are currently maintained on LifeCare’s Team Website. Access information:

LifeCare Log-In http://www.lifecaretherapy.com Instructions: Click on the “Team” tab at the top of the screen.

Enter User Name: life (case sensitive) Enter Password: care (case sensitive)

Step 3: Download Paperwork You will need to complete Therapist Sign-On Package Part I and Part II. You will need to download and save the forms for your use. There are two options:

1. Rick click on the form and choose “Download File As” to save your computer/tablet. 2. Open the form and “click” the red “Save Me” button at the top.

Step 4. Complete Paperwork 3A. Open Adobe Acrobat DC. 3B. Open file saved to your computer. 3C. Use “tab” key to forward from field to field. 3E. Save and close document. Attachments that have not already been submitted can be sent via scan, fax or by taking a “picture” of the document on your phone and submitting this via-email. Step 5: Copy / Scan / E-Mail (Preferred) / Fax Completed Information To:

E-Mail: [email protected]

Fax: 866-718-5759

LifeCare Therapy Services

Rehabi l i ta t ion Therapy and Disease Management

Checklist for Documents Needed

Part I: Regulatory Date Sent E-Signature Agreement

Therapist Demographic Sheet

W-9 Form

Therapy IC Agreement/Contract

Attachment A: Rate Sheet

Direct Deposit Authorization

Confidential Background Check Authorization

AHCA Affidavit of Compliance with Background Screen

Part II: LifeCare Orientation Date Sent Acknowledgement of Receipt of LifeCare Policies

Acknowledgement of Receipt of Patient Care Policies

Code of Ethics

Clinicient Access & Utilization Agreement

HIPAA Privacy & Confidentiality: Acknowledgement of Understanding

Regulatory Compliance Guidelines for Therapists

Self-Certification to Prevent Fraud

Hepatitis B: Complete or Statement of Decline

Attachments/Copies Needed Date Sent Resume

- Licenses & Certifications

Professional License

Proof of Professional Liability Insurance

County Business Tax Receipt License

CPR Card

Florida Driver’s License

Automobile Insurance Card / Policy Declaration

- Health Information

Physical Exam / Statement of Good Health

PPD Test

Hepatitis Vaccination (or Statement of Decline Above)



Date Completed:

Name: DOB: __________________ SSN: Company Name (If Applicable): TIN: Mailing Address:

City: State: Zip:

Therapy License Number: Licensed In: Expiration:

Driver’s License Number: Licensed In: Expiration:

Contact Information Primary Contact (Mobile) Telephone: Home:

Alternate Telephone: Fax:

E-Mail:

Emergency Medical Information Do you have any medical condition, past or present, that we would need to be aware of in case of a medical emergency?

No Yes, If yes, please describe:

Do you have any allergies that we need to be aware of in case of a medical emergency? No Yes If yes, please describe:

Whom would we contact in case of an emergency?

Name Relationship Contact #

Scheduling Notes (Preferred Practice Area)

By checking this box and by adding my name/signature below, I certify that the above information is true and correct. I certify that I am a therapist, licensed to practice without restriction in the State of Florida and that my license is current. I certify that I have and will maintain liability insurance and that valid proof of this coverage will be provided to LifeCare to maintain in my personnel record.

Therapist Name/Signature Date

Therapist Demographic Sheet



Electronic Signatures

Acknowledgement of Understanding

LifeCare utilizes e-signatures for Contracts, Acknowledgements of Understanding and Agreements between our Company and Individuals who have applied to our organization for either an employment or independent contractor position. The Electronic Signatures in Global and National Commerce Act (E-SIGN) facilitates the use of electronic records and electronic signatures by ensuring the validity and legal effect of contracts that are entered into electronically. The E-SIGN Act states that a contract or signature “may not be denied legal effect, validity, or enforceability solely because it is in electronic form”. This statement provides that electronic signatures and records are equivalent to paper signatures and, therefore, subject to the same legal scrutiny of authenticity that applies to paper documents.

This Agreement outlines LifeCare’s intent to utilize e-signatures as part of our hire/contract practices. You must acknowledge both your acceptance and understanding of these requirements by checking each box below, typing your Initials and then “typing” your signature at the end of this Agreement.

I agree that the documents contained herein may be electronically signed. I understand that the electronic signatures appearing on these documents are the same as handwritten signatures for the purposes of validity, enforceability and admissibility. Initials:

I understand that my acknowledgement of understanding and agreement will be demonstrated by a two part process of adding a “Check” to each box when requested to do so and then typing either initials and/or name next to each statement. These steps will constitute my legal signature. Initials:

I further understand that I have the right to withdraw my consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent, I will notify LifeCare of my wish to withdraw consent and request that future documents, notices and disclosures be provided in paper format. To request paper copies of documents; withdraw consent to conduct business electronically and receive documents, notices or disclosures electronically; or withdraw consent to sign documents electronically, I will submit a request in writing to LifeCare by postal mail or email. Initials:

Mailing Address: 7777 North University Drive Suite 101-South Tamarac, FL 33321

E-mail: [email protected] Therapist Signature Date

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Therapy Services

INDEPENDENT CONTRACTOR AGREEMENT

This Independent Contractor Agreement is entered into between LifeCare of Florida, LLC ("Company") and ("Contractor").

WHEREAS, Company is in the business of providing medical rehabilitation programs and wishes to contract with Contractor to provide therapy services to its rehabilitation patients at it’s on-site and off-site locations, and;

WHEREAS, the Contractor is a licensed registered in the State of Florida and desires to provide such professional services to the

Company.

NOW THEREFORE, in consideration of the foregoing and of the promises and covenants contained herein the parties agree as follows: 1. GENERAL COVENANTS:

A. SERVICES: Contractor agrees to provide professional services to the company at the above referenced on-site and off-site locations.

B. LICENSING: Contractor warrants that it is properly licensed, in the State of Florida, to perform

the services and do business as contemplated by this agreement. Contractor agrees to provide Company proof of same prior to commencement of the services set out herein and from time to time thereafter as requested by the Company.

C. QUALITY OF SERVICES: Contractor agrees to perform such services in a professional,

workmanlike manner to the standards established by the Appropriate National Association and consistent with the policies, procedures, philosophy, and quality standards established from time to time by the Company. Contractor shall supply said services in a method consistent with the standards of care as defined by State Law.

D. HEALTH REQUIREMENTS: Contractor will provide, to the Company, at Contractor's expense,

evidence that he/she meets all health requirements imposed by the Company, State, or any other applicable regulatory or government agency.

E. CERTIFICATION: Contractor certifies that they have not been convicted of an offense that would

preclude employment in a nursing home, assisted living facility, skilled nursing facility, off-site or on-site rehabilitation location and is not currently ineligible for participation in, or been excluded from participation in any Federal health care program.

F. PROPRIETARY INFORMATION: Contractor hereby acknowledges Company's proprietary

information and systems and Company’s right to protect such. At all times while this Agreement is in force and after its termination, the Contractor agrees, unless mutually agreed by company in writing to the contrary, to refrain from disclosing, contacting or proselytizing the Company's clients, patients, trade secrets, or other confidential material and information, including manuals, forms and

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marketing materials and agrees that such would be a material breach of this agreement causing damage

to the Company. The Contractor agrees to refrain from the following at all times:

I. Providing any other type, except of what is assigned, of care, to any LifeCare patient whether compensated or not.

II. Recommending to LifeCare’s patients another provider of any type of service, and/or referring LifeCare’s patients to another provider of any type without the express permission from Company and understands that doing so shall damage Company.

III. Company patients include any patients referred directly to contractor from Company, that contractor treated on behalf of Company, and was billed as a patient of Company.

G. CONVENIENCE: Contractor agrees to perform its services at a time convenient to its

patients, Company, and other therapists.

H. OTHER CONTRACTS: Company acknowledges that Contractor provides the same or similar services at other facilities for other providers and consents to such activity so long as Contractor is able to fulfill its obligations under the terms of this agreement.

I. EQUIPMENT/TOOLS: Contractor agrees to provide any customary equipment or tools necessary for

the performance of the services provided under this agreement.

2. INVOICING AND PAYMENT PROCEDURE:

A. COMPENSATION PAID TO CONTRACTOR: The Company agrees to pay Contractor for billable Contractor's time which includes direct patient therapy only. Contractor's billable time does not include travel and personal time. Rates are describes in Attachment A.

B. DOCUMENTATION: Contractor will provide the Company with the following documentation,

which the Company determines to be sufficient, to assure the Company that all services rendered by the Contractor are medically and clinically necessary and to enable the Company to submit to the proper reimbursement source all bills for services rendered. Any changes must be given with thirty days written notice to the Contractor.

C. DOCUMENTS TO BE PROVIDED: The Contractor and its agents agree to provide and maintain

the following items in addition to any other documentation that may be required from time to time by the Company:

I. Written documentation for the individual patient as may be required by the Company, federal or

state governmental agencies or other third party reimbursement sources to detail treatment, progress, and evaluations; and

II. Such reports and completed reimbursement forms as may be necessary to document and substantiate to federal and state governmental agencies or other third party reimbursement sources the nature and results of the services delivered by the Contractor. The Contractor shall, upon request, make available for the Company's inspection such records as are maintained by the Contractor for the Company's patients.

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D. INVOICES:

I. Preparation and Submission: The Contractor shall submit to the Company invoices for all services rendered. Such invoices shall include, among other items:

A. the name of the therapist who provided the services; B. the name(s) of the patients to whom the services were rendered.

2. Payment:

A. The Company shall pay in full any invoice submitted by the Contractor to the

Company pursuant to this section on or before the 15th day after the invoice was submitted when included with completed documentation as set forth in paragraphs II(B) and II(C).

B. Twice monthly according to a printed schedule.

E. CLAIMS AND DISPUTES:

The Contractor shall cooperate with and shall provide full documentary support for the Company with regard to assisting the Company in any dispute or claim by any third party reimbursement source arising out of any invoice which the Company has received from the Contractor. Contractor's assistance shall be on its own time and at its own expense.

3. INSURANCE:

Prior to the date on which the Contractor commences performing under this agreement, the Contractor shall submit to the Company a policy or certificate of insurance indicating that the Contractor has appropriate coverage for any acts of professional malpractice and general liability committed by the Contractor and its agents. The coverage shall be provided by an insurer whose reputation and financial viability is acceptable to the Company. Said coverage shall be in the amounts agreeable to the Contractor and the Company. But, in any event, not be less than One million Dollars ($1,000,000) aggregate per year.

4. ACCESS TO RECORDS OF CONTRACTOR:

Until the expiration of four (4) years after the furnishing of services pursuant to this agreement, the Contractor agrees to make available, upon request from the Secretary of Health and Human Services or the U.S. Comptroller General or of any of their duly authorized representatives, this agreement and any books, documents, and records of the Contractor that are necessary to certify the extent of costs incurred by the Company under this agreement.

5. EMPLOYEE BENEFITS:

The Contractor is solely responsible for maintaining all employment, tax, and other records of its employees; for making contributions under any applicable unemployment benefit act, workers' compensation act, or other employee benefit act; and for maintaining any and all employee insurance as may be required by law. Further, Contractor shall comply with all state, federal, and local laws and regulations and licensing requirements.

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6. TERM:

This agreement shall commence upon execution, in accordance with the terms hereof and shall continue in full force and effect for one year or unless earlier terminated by the parties. Either party may terminate this agreement with cause at any time, cause to be defined as misfeasance or malfeasance, and without cause upon thirty (30) days written notice, unless both parties agree in writing to an earlier termination date.

Unless this agreement is otherwise terminated, upon the expiration of the initial term, or any extension thereof, such term shall be automatically extended for an additional one year upon the same terms and conditions as contained herein, unless either party notifies the other in writing to the contrary at least thirty (30) days prior to such expiration. Contract may renew, year over year, for a period of up to five (5) years.

All provisions of this agreement, including any schedules and written modifications, shall remain in full force and effect throughout the thirty-day period following receipt of a written notice of termination.

No additional rights or obligations shall accrue under this agreement on the part of either party after termination of this agreement, except that the parties shall have the right to claim and receive payments due through the date of termination.

7. ASSIGNMENT LIMITED:

Without the consent of the other contracting party, this contract cannot be assigned except where all or substantially all of the assets or stock of either contracting party has been sold. In the event of such a sale, any and all fee agreements will remain in full force.

8. NUMBER OF DAYS:

In computing the number of days for purposes of this agreement, all days shall be counted, including Saturdays, Sundays, and legal banking holidays; provided, however, that if the final day of any time period falls on a Saturday, Sunday or holiday, the final day shall be deemed to be the next day which is not a Saturday, Sunday, or holiday.

9. VARIATIONS OF PRONOUNS:

All pronouns and all variations thereof shall be deemed to refer to the masculine, feminine, or neuter, singular or plural, as the identity of the person or persons or entity may require.

10. RIGHTS:

Neither the failure nor any delay on the part of any party to exercise any right, remedy, power, or privilege ("Right") under this agreement shall operate as a waiver thereof, nor shall any single or partial exercise of any Right preclude any other or further exercise of the same or of any other Right, nor shall any waiver of any Right with respect to any occurrence be construed as a waiver of such Right with respect to any other occurrence. No waiver shall be effective unless it is in writing and is signed by the party against whom such waiver is being asserted.

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11. CAPTIONS AND HEADINGS:

The captions and headings throughout this agreement are for convenience and reference only, and the words contained herein shall in no way be held or deemed to define, limit, describe, explain, modify, amplify, or add to the interpretation, construction, or meaning of any provision of or to the scope or intent of this agreement nor in any way affect the agreement.

12. INDEMNIFICATION:

The Company shall indemnify and hold the Contractor harmless from and against all claims, demands, costs, expenses, liabilities and losses (including reasonable attorney's fees) which may result against the Contractor as a consequence of any alleged malfeasance, neglect, dishonesty, willful misconduct or medical malpractice caused or alleged to be caused by the Company, its employees, agents, or contractors.

The Contractor shall indemnify and hold the Company harmless from and against all claims, demands, costs, expenses, liabilities, and losses (including reasonable attorney's fees) which may result against the Company as a consequence of any alleged malfeasance, neglect, dishonesty, willful misconduct or medical malpractice caused or alleged to be caused by the Contractor, its employees, agents, or contractors.

13. ATTORNEY’S FEES:

In the event that either party institutes litigation to interpret or enforce any provision of this agreement, the prevailing party shall be entitled to reasonable attorney's fees and costs incurred at all stages of the proceedings, including appellate proceedings.

14. INDEPENDENT CONTRACTOR AGREEMENT:

This agreement is an independent contract between the parties. Neither party shall be construed in any manner whatsoever to be an employee or agent of the other, nor shall this agreement be construed as a contract of employment or agency.

15. COMPLIANCE WITH TITLE VI OF THE CIVIL RIGHTS ACT OF 1964:

The parties agree to be in full compliance with Title VI of the Civil Rights Act of 1964 (P.L. 8B-352) and all requirements imposed by and pursuant to the regulations of the United States Department of Health and Human Services issued pursuant to that Title, so that no person in the United States of America shall, on the grounds of race, color, handicap, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity provided by the parties.

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16. MEDICARE CONTRACT REQUIREMENTS:

A. This contract or agreement must be renewed after a period of five (5) years.

B. If any clause in this contract is found by any regulatory agency to be in conflict with the law, the clause can be unilaterally amended by Company with notice to Contractor.

C. Contractor understands that Company must retain professional and administrative responsibility for, and

control and supervision of, all services rendered. D. Contractor understands that only the Company may bill the Beneficiary for covered services that are

furnished under this arrangement and Contractor may not bill the patient or Medicare for services rendered. Receipt of Medicare payment to the Company, on behalf of the beneficiary, fully discharges the liability of the individual or any other person to pay for those services.

E. In instances where Protected Health Information, herein referred to as “PHI” is given by the Company, it is

agreed that the Contractor shall:

1. Comply with the applicable provisions of the Administrative simplification section of the Health Insurance Portability and Accountability Act of 1996, as codified at 42 U.S.C § 1320d through d-8 (“HIPAA”), and the requirements of any regulations promulgated thereunder,

2. Not use or further disclose any PHI concerning a patient other than as permitted by this Agreement, the requirements of HIPAA and/or applicable federal regulations. Contractor shall implement appropriate safeguards to prevent the use or disclosure of a patient’s PHI other than as provided for by this Agreement,

3. Promptly report to Company any violations, use and/or disclosure of a patient’s PHI not provided for by this Agreement as soon as practicable, upon becoming aware of the improper violations), use and/or disclosure.

17. BREACH OF CONFIDENTIALITY:

In the event that either party is in material breach of any provision(s) of this Agreement, it shall immediate advise the opposite party and take steps to remedy such breach, including, but not limited to, protecting against the consequences of any disclosure or use of PHI in violation of this Agreement. Both parties acknowledge that use and disclosure of PHI, in any manner inconsistent with this Agreement, may result in irreparable and continuing damage. As applicable by law, legal remedies, such as equitable relief, may be necessary to protect against any such breach or threatened breach, including, without limitation, injunctive relief. Company and Contractor have acknowledged their understanding of and agreement to the mutual priorities written above by executing this Agreement.

18. NOTICES:

All notices given by either party to the other under this contract shall be in writing. All notices, demands, and requests shall be deemed given when mailed, postage prepaid, by registered or certified mail, return receipt requested as follows: 1. to the Company at:

LifeCare of Florida 7777 North University Drive, Suite 101-S Tamarac FL 33321

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2. to the Contractor at:

19. GOVERNING LAWS:

This agreement shall be governed by the laws of the State of Florida. 20. OTHER AGREEMENTS AND PARTIES:

This agreement, containing the final and complete understanding between the parties, may be altered or modified only by subsequent written instrument executed by both parties, and shall bind and inure to the benefit of the parties and their respective successors and assigns. IN WITNESS WHEREOF, the parties hereto have executed this agreement:

LifeCare of Florida, LLC By: , as it’s Title: Date:

By checking this box and entering my name below to this Agreement, I understand and accept that this

agreement is legally binding. “Contractor” Signature:

Date:

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Therapy Services

INDEPENDENT CONTRACTOR AGREEMENT

Attachment A Rates

COMPENSATION RATE

Evaluation Rate $

Treatment Rate $

Supervision Visit Rate* $

Discharge Visit Rate* $

Travel Rate $

By checking this box and entering my name below to this Agreement, I understand and accept

that this agreement is legally binding. Contractor Signature Date



ACH AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS (ACH CREDITS)

Company Name: LifeCare of Florida I hereby authorize LifeCare of Florida, hereinafter called COMPANY, to initiate credit entries and, if necessary, debit entries and adjustments for any credit entries in error to my (our) account at the depository Financial Institution named below, and to credit or debit the same from such account. I (we) agree that the authority will remain in effect until I have (or either of us) cancelled it in writing and that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law. Financial Institution: Branch: City ________________________________________ State _________ Zip __________________ Routing Number: Account #: This is a Checking Account or Savings Account This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time, and in such manner as to afford COMPANY and Financial Institution a reasonable opportunity to act on it. By checking this box and entering my name below, I understand and accept that this agreement is legally binding and certify that the information contained in this Authorization is correct to the best of my knowledge. Name/Signature Date

(Please Provide a Voided Check)



Confidential Background Check Authorization

Last Name First Name Middle

Former Name / Alias Dates Used

Date of Birth Social Security Number

Driver’s License Number State Issued

Current Address

City State Zip

____ I Have Not undergone Level or background screening (fingerprinting) with the Agency for HealthCare

Administration OR _____ I Have undergone Level II Background Screening (fingerprint) with the Agency for HealthCare

Administration. The screening was conducted on or about _______________________(date) when I was

employed or performed contract work with ______________________________________________(Agency).

_____________________________________________________________________________________________ I hereby authorize LIfeCare of Florida and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for contract, employment or volunteer purposes. I understand that the scope of the report may include, but is not limited to the following areas: verification of social security number;; credit reports;; current and previous residences;; employment history;; education background and license verification;; character references;; drug testing;; civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions;; driving records;; birth records and any other public records. I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to LifeCare of Florida or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation or public agency may have, to include information or data received from other sources. LifeCare of Florida and its agents shall maintain all information received from this authorization in a confidential manner to protect my personal information including, but not limited to, addresses, social security number, and date of birth. By checking this box and entering my name below, I understand and accept that this agreement is legally

binding and certify that the information contained in this Authorization is correct to the best of my knowledge.

Signature Date

AHCA Form # 3100-0008, August 2010 Section 59A-35.090(3)(b)2, Florida Administrative Code Page 1 of 3 Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml

Authority: This form may be used by all employees to comply with: • the attestation requirements of section 435.05(2), Florida Statutes, which state that every

employee required to undergo Level 2 background screening must attest, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to this chapter and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses while employed by the employer; AND

• the proof of screening within the previous 5 years in section 408.809(2), Florida Statutes which

requires proof of compliance with level 2 screening standards submitted within the previous 5 years to meet any provider or professional licensure requirements of the Agency, the Department of Health, the Agency for Persons with Disabilities, the Department of Children and Family Services, or the Department of Financial Services for an applicant for a certificate of authority or provisional certificate of authority to operate a continuing care retirement community under chapter 651 if the person has not been unemployed for more than 90 days.

This form must be maintained in the employee’s personnel file. If this form is used as proof of screening for an administrator or chief financial officer to satisfy the requirements of an application for a health care provider license , please attach a copy of the screening results and submit with the licensure application.

Employee/Contractor Name:

Health Care Provider/ Employer Name:

LifeCare of Florida

Address of Health Care Provider: 7777 N University Drive, Suite 101-S Tamarac FL 33321

I hereby attest to meeting the requirements for employment and that I have not been arrested for or been found guilty of, regardless of adjudication, or entered a plea of nolo contendere, or guilty to any offense, or have an arrest awaiting a final disposition prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction:

Criminal offenses found in section 435.04, F.S

a) Section 393.135, relating to sexual misconduct with certain developmentally disabled clients and reporting of such sexual misconduct.

(b) Section 394.4593, relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct.

(c) Section 415.111, relating to adult abuse, neglect, or exploitation of aged persons or disabled adults.

(d) Section 782.04, relating to murder.

(e) Section 782.07, relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child.

(f) Section 782.071, relating to vehicular homicide.

(g) Section 782.09, relating to killing of an unborn quick child by injury to the mother.

(h) Chapter 784, relating to assault, battery, and culpable negligence, if the offense was a felony.

(i) Section 784.011, relating to assault, if the victim of the offense was a minor.

(j) Section 784.03, relating to battery, if the victim of the offense was a minor.

(k) Section 787.01, relating to kidnapping.

(l) Section 787.02, relating to false imprisonment.

(m) Section 787.025, relating to luring or enticing a child.

AFFIDAVIT OF COMPLIANCE WITH Background Screening

Requirements


(n) Section 787.04(2), relating to taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceedings.

(o) Section 787.04(3), relating to carrying a child beyond the state lines with criminal intent to avoid producing a child at a custody hearing or delivering the child to the designated person.

(p) Section 790.115(1), relating to exhibiting firearms or weapons within 1,000 feet of a school.

(q) Section 790.115(2)(b), relating to possessing an electric weapon or device, destructive device, or other weapon on school property.

(r) Section 794.011, relating to sexual battery.

(s) Former s. 794.041, relating to prohibited acts of persons in familial or custodial authority.

(t) Section 794.05, relating to unlawful sexual activity with certain minors.

(u) Chapter 796, relating to prostitution.

(v) Section 798.02, relating to lewd and lascivious behavior.

(w) Chapter 800, relating to lewdness and indecent exposure.

(x) Section 806.01, relating to arson.

(y) Section 810.02, relating to burglary.

(z) Section 810.14, relating to voyeurism, if the offense is a felony.

(aa) Section 810.145, relating to video voyeurism, if the offense is a felony.

(bb) Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony.

(cc) Section 817.563, relating to fraudulent sale of controlled substances, only if the offense was a felony.

(dd) Section 825.102, relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult.

(ee) Section 825.1025, relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult.

(ff) Section 825.103, relating to exploitation of an elderly person or disabled adult, if the offense was a felony.

(gg) Section 826.04, relating to incest.

(hh) Section 827.03, relating to child abuse, aggravated child abuse, or neglect of a child.

(ii) Section 827.04, relating to contributing to the delinquency or dependency of a child.

(jj) Former s. 827.05, relating to negligent treatment of children.

(kk) Section 827.071, relating to sexual performance by a child.

(ll) Section 843.01, relating to resisting arrest with violence.

(mm) Section 843.025, relating to depriving a law enforcement, correctional, or correctional probation officer means of protection or communication.

(nn) Section 843.12, relating to aiding in an escape.

(oo) Section 843.13, relating to aiding in the escape of juvenile inmates in correctional institutions.

(pp) Chapter 847, relating to obscene literature.

(qq) Section 874.05(1), relating to encouraging or recruiting another to join a criminal gang.

(rr) Chapter 893, relating to drug abuse prevention and control, only if the offense was a felony or if any other person involved in the offense was a minor.

(ss) Section 916.1075, relating to sexual misconduct with certain forensic clients and reporting of such sexual misconduct.

(tt) Section 944.35(3), relating to inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm.

(uu) Section 944.40, relating to escape.

(vv) Section 944.46, relating to harboring, concealing, or aiding an escaped prisoner.

(ww) Section 944.47, relating to introduction of contraband into a correctional facility.

(xx) Section 985.701, relating to sexual misconduct in juvenile justice programs.

(yy) Section 985.711, relating to contraband introduced into detention facilities.

(3) The security background investigations under this section must ensure that no person subject to this section has been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense that constitutes domestic violence as defined in s. 741.28, whether such act was committed in this state or in another jurisdiction.

Criminal offenses found in section 408.809(4), F.S

(a) Any authorizing statutes, if the offense was a felony.


(b) This chapter, if the offense was a felony.

(c) Section 409.920, relating to Medicaid provider fraud.

(d) Section 409.9201, relating to Medicaid fraud.

(e) Section 741.28, relating to domestic violence.

(f) Section 817.034, relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems.

(g) Section 817.234, relating to false and fraudulent insurance claims.

(h) Section 817.505, relating to patient brokering.

(i) Section 817.568, relating to criminal use of personal identification information.

(j) Section 817.60, relating to obtaining a credit card through fraudulent means.

(k) Section 817.61, relating to fraudulent use of credit cards, if the offense was a felony.

(l) Section 831.01, relating to forgery.

(m) Section 831.02, relating to uttering forged instruments.

(n) Section 831.07, relating to forging bank bills, checks, drafts, or promissory notes.

(o) Section 831.09, relating to uttering forged bank bills, checks, drafts, or promissory notes.

(p) Section 831.30, relating to fraud in obtaining medicinal drugs.

(q) Section 831.31, relating to the sale, manufacture, delivery, or possession with the intent to sell, manufacture, or deliver any counterfeit controlled substance, if the offense was a felony.

If you are also using this form to provide evidence of prior Level 2 screening (fingerprinting) in the last 5 years and have not been unemployed for more than 90 days, please provide the following information. A copy of the prior screening results must be attached. Purpose of Prior Screening:

Screened conducted by: Date of Prior Screening:

Agency for Health Care Administration Department of Health Agency for Persons with Disabilities Department of Children and Family Services Department of Financial Services

Affidavit Under penalty of perjury, I, , hereby swear or affirm that I meet the requirements for qualifying for employment in regards to the background screening standards set forth in Chapter 435 and section 408.809, F.S. In addition, I agree to immediately inform my employer if arrested or convicted of any of the disqualifying offenses while employed by any health care provider licensed pursuant to Chapter 408, Part II F.S. Employee/Contractor Signature Title Date

Connie

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Business Tax Receipts As a company that is certified by Medicare, LifeCare is required to comply with all applicable federal, state and local regulations. One local regulation requirement is the use of Business Tax Receipts (formerly occupational licenses) for any individual or business that provides either goods or services within a county or city. These regulations apply to the provision of therapy services as either a business or as an Independent Contractor. The requirements vary by county and links are provided below to assist you in the application process. Please note that this is not a requirement of LifeCare but a local county regulatory requirement in which we are assisting you with compliance.

Miami-Dade County Who Must Apply: PT, OT, SLP, PTAs, COTAs Website: https://www.miamidade.county-taxes.com/btexpress

Broward County Who Must Apply: PT, OT, SLP

Assistants do not need to apply Website: www.broward.county-taxes.com/btexpress

Palm Beach County Who Must Apply: PT, OT, SLP

Assistants do not need to apply Website: https://pbctax.com/services/local-business-tax-services/local-business-tax-receipts

Martin County Who Must Apply: PT, OT, SLP, PTAs, COTAs Note: In Martin County, you must apply through the city in which you reside or your

business is located. Please check your local city government/tax page for information. In Stuart, the information must be provided in-person or by mail. http://www.cityofstuart.com/index.php/dept/business-tax-division

Port St. Lucie County Who Must Apply: PT, OT, SLP, PTAs, COTAs

City of Port St Lucie: Must be in person http://pandapublicweb.cityofpsl.com/Businesstax/home.aspx

Ft Pierce: Must be In Person

http://cityoffortpierce.com/141/Applications

https://miamidade.county-taxes.com/btexpress

https://broward.county-taxes.com/btexpress

http://www.cityofstuart.us/index.php/departments/business-tax

http://pandapublicweb.cityofpsl.com/Businesstax/home.aspx

http://cityoffortpierce.com/141/Applications