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All VIP Care 

Dear Independent Contractor: 

Your application for work/assignment is a legal document. 

Therefore, falsifying documents is a criminal offense and is considered to be a 

white-collar crime. This involves altering, changing, modifying, passing or 

possessing documents for an unlawfu] purpose. Including putting false information 

on your application. 

This WILL result in immediate termination from All VIP Care, Inc. roster and your 

certificate/license will be reported to the state/Palm Beach County. 

By signing below, you are stating your application is truthful to the best of your 

knowledge. 

5--3-2/ r 

Signature Date 

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I 

I 

I 

i 

I 

l 

I 

I 

I 

APPLICATION FOR CONTRACT OR EMPLOYMENT WITH THE REGISTRY 

Section 2: Desired Employmerit or Contract 

Position: Lt' ,__,, f\ / \ Date Available to start r,:...,, --✓ l;;c-/,,- c,_z::_~~ 

Are you currently employed? __ Y'_N 

If employed, may we contact your current employer(s}? V ,,, N 

Have you applied to Our nurse registry before? _y _,... 

lfso, when? 

sectton 3: Education 

-"···-·-·--

Years Type of Stho.ol Name Address/Location Attended 

High School (J/412'a> C/a '/9-, VtfllzZVl ' , " - College 

·---

Graduate SchOol 

Trade, Business, 

or Specialty 

School 

Date Diploma/Degree Graduated 

Section 4; Employment/Contractual History {list in chronological order wirh last ar-presentemplayerffr.st) 

Employer. _---, I / ✓ , / ,.r 1 /£'.'_' ___ ~ Jilob title: -- Address: 

Phone: ---· Duties: 

Date from: -- I Dateto: I Salary: I Name of Supervisor: 

Reason for leaving: 

Emp.loyer: I Job title: - A,ddress: 

Phone: I Duties: 

Date from: I Dateto: I Salary: I Name of Supervisor: 

R'eason for leaving: 

Employer: -- I Job title: 

Address: 

Phone: ···- I Duties: 

Date from: I Dateto: I Salary: I Name of Supervisor: 

© 2014 A!ilance Consu!ting Services of F!orjda,, In~. I 

"------- ---------------·---"-

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I Reason for leaving: 

~plover: I Job title: 

Address_: 

Phone: I Dutie_s: >---~-----------+-~----------. ·----- Date from: I Date to: ! Salary: I Name of Supervisor: 

Reason for leaving: 

Employer: I Job title: 

Address: 

>-~=------ .... ---~---·----------------------1 Phone: I Duties: f.',=='----~~-------t===----~--~~-~--------·-

Date from: I Date to: I Salary: I Name of Supervisor_: 

Reason for leaving: ~:=:=--;,=="'-~~-------.-~-- If addit,onal space 1s required, p!ease-uti/iie the back of the opphr:ut1on form ta /,:st additional past employerY>. 

Section 5· Professional License-(s-J Registration{s), and/or Certification{s) ' 

Type Llcense/Certiflcatio_n # Date Issued Expiration/ State Issued Renewal Date ------

~ .. .. 

ADDITIONAL INFORMATION: 

Are.you eligibletoworJ-, in the United States? __ Yes __ No 

If No, why-not? ________________________________ _ 

Are you wtllingtowork any shift, including-nights and weekends? 

Are you willing to accept a live--in assignment? 

__ Yes __ No 

__ Yes __ No 

How soon following notification can you start? ____________________ _ 

Please indicate days and our vailable to work. 

indicate below as weir. 

No Preference 

Monday 

Tuesday 

Wednesday 

Thursday 

Friday 

Saturday 

Sunday 

lf you are unaval!able on certain days/times, please 

Have you ever been convicted of a crime? __ Yes 

If yes, explain number of conviction{s), nature of offense(s) leading to convictl n(s), how recently such 

offense(s) was/were committed, sentence(s) imposed, and type of rehabilit/on 

Have you had a break in providing servlces under your license or byes _No _N/ A 

certification for greater than 90 days? 

© 2014Aflianc:e Consulting Services of Florida, u,c. 

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Have you maintained continuous U.S. residency for at least five years? 

Do you have a valid driver's license? 

--'r-No 

-~_No N/A 

LanguagesSpoken:---..S_.......o_/~o __ U=-:;S;.--r~-~-it.J---'--e>=------t/----------- languages Read/Written:. ____________________________ _ 

Additional information/skills/knowledge/license(s) applicable to position you are applying for: ___ _ 

Statement Regarding Application: The information contained on this application is complete and 

accurate. I hereby authorize verification of any and all information contained in this application and on 

my resume, if provided. I certify that such statements are true, and understand that misrepresentation 

or omission of facts called for in this form, or on any resume provided by me, is cause for termination of • employ o ct without n i . 

Date 5- 2 ~ 2/ 

THIS NURSE REGISTRY IS AN EQUAL OPPORTUNITY EMPLOYER. NO PERSON SHAU BE DENIED 

EMPLOYMENT ON THE BASIS OF RACE, AGE, ETHNICITY, NA T10NAL ORIGIN, GENDER, SEXUAL 

ORIENTATION, RELIGION, CREED, VETERAN STATUS, MARITAL STATUS, DISABILITY OR ANY OTHER 

LEGAU Y PROTECTED STATUS. Employment or contract is contingent upon furnishing evidence of 

identity, employment eligibility, and qualifications. 

© 2014 Alliance Consulting Services of Florida, Inc. 

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ACKNOWLEDGMENT OF 

NURSE REGISTRY POLICY & PROCEDURE 

l CONFIDENTIALITY STATEMENT Initials:/' \ J' 

l understand that the nurse registry abides by all standards set out by state and federal privacy Jaws{i.e. 

HIPAA). I have been instructed on maintaining the confidentialltv" of medical records1 the privacy of clie.nt's 

protected health information {PHI), as well as any other proprietary information regarding the nurse registry. I 

am aware of and understand the nurse registry's policies relating to use, collection, disclosure, storage, c1nd 

destructlbn of client's PHI. I un_derstan.d that medical information regarding the client may-only be discussed 

with authorized individuals. l hereby pledge that I will not access or use client's PHI except as required in the 

course of my duties and in accordance with applicable legislation and the nurse registry's policies. I will take 

the appropriate measures to keep confidential all PHI and proprietary information r¢garding the nurse registry 

both during my employment and after my employment or association ends with the nurse registry. NurS.e 

registry records, including personnel files and manuals, are deemed privileged and confidential and shall be 

stored and maintained in such a manner as·to maintain their confidentiality. I acknowledge th_at any 

unauthorized use or di.Sclosure of a dient's health inform::ition or breach of confidentiality with the nurse 

registry will result in disciplinary action up to and including termination of employme·nt or my.contract. 

" ---- .. _,_ ~- ·~~·-·-' ----· 

TAK EXEMPT STATUS Initials: ('J; y··~-~ 

I hereby ackn·owledge that·! am an Independent Contractor working for the registry. Therefore, I am 

responsible for applicable state and federal taxes, such as Social Security. I also acknowledge that I will receive 

an IRS Form 1d9_9 for each year-that I am a subcontractor of the registry. This form will also be sent to the 

Internal Revenue Service (IRS). As an independent contractor, I further acknowledge that! am not eligible to 

receive ·any benefits such as vacations, health insurance, disability, or unemployment and will not be covered 

by Worker's Compensation or other irisurance policies of the registry. I agree to maintain insurnnce coverage 

and policies applicable to my profession, if indicated. 

----~- PERFORMANCE REVIEW Initials:(~ .... , V 

J have been informed that my work performance will be evaluated on an ongoing basis.and that I will receive a' 

written evaluation of my work performance by each facility to which! am referred for an assignment on an 

annual basis. I understand that l will also be assessed by the reglstry for competency as it relates to the 

performance of my job duties. 

CODE OF CONDUCT Initials: t ,- \ / 

It is the objective of the nurse registry to provide services in accordance with -al! applicable laws, regulations 

and stututes. The nurse registry believes that its independent contractors share this objective and wtsh to 

perform their jobs in a competent,. legal and ethical manner and thus, have establfshed a Code of Conduct as a 

demonstration of that commitment. I hereby certify that I have received, read and agree to abide by th ls-Code 

of Conduct. Therefore, f agree to: 

o Always perform my duties and responsibilities to the best of my ability. 

e Treat all clients with care, courtesy-and respect and maintain client confidentlafity at all times. 

• Protect all client rights and report any failure to observe client rights by any person promptly . 

,. Always speak truthfully to all persons with whom I have contact in the·course of my d_uties, including clients, 

family members, other independent contractors and government officials. 

• Obey all laws -Which iTiay apply to the performance.of my duties, 

• Make !,Ure all documents or records which I prepare contain only accurate and truthful information . 

• Observe al! other standards of conduct which apply to my position . 

• Report·any activities that may violate this Code of Conduct to the nurse registry's own.er . 

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I 

DRUG ANO ALCOHOLSCREENING Initials: II' v . v 

I understand that the nurse registry is a-drug free workplace, I understand that urine and/or blood testing for 

alcohol and/or drug use may be requested during the course of my cantractu<1l relationship with the registry. 

St!ch testing may be randomly·requested or requested due to-the registry's suspidon that l airr under the 

influence of alcohol and/or drugs that have the potential to result in an on-the-fob injury or negatively impact 

the .quallty of my work and/or the: safety and quality ot care 1 provide to nurse registry c_tients or the f_aci\ities 

with which I work. I authorize that such testing may be requested of me at the discretion of nurse registry 

management. I accept this as a condition of my contract. I agree to allow such testing to be completed at a 

time and place to be chosen by registry management. I further authorize the results of such testing to be 

rel'eased to the registry and any facility or business to which I am referred for assignment by the registry. 

APPLICATION FOR CONTRACT REVIEW: Initials: 

I certify that the information! have provided during the course of applying for this position ;md interviewing 

with the nurse registry is true and correct, including but not limited ta the application, my resume, and 

documentation for my registration folder/personnel file. I authorize the exchange of information required for 

the nurse registry to complete a-thorough investigation of my work history and' qualifications. I hereby release 

from liability all persons who provide information to the nurse registry during the course of any such 

Investigation. I understand that any falsification of information on my behalf may subject me to immediate 

termination of my contract with the registry. 

Should I be offered a contractor position with the nurse regiStry, I have read and agree to the terms specified 

in the job description provided. J understand that! rnay be asked to performed additional responsibilities as 

applicable to my position with the nurse registry and perthe·requestofmanagemenL I agree that, as a 

requirement of my employment or-contract, that I will provide the nurse registry with a 14day written 

advance notice of intent to terminate my contract. I agree to comply with OSHA standards under the 

Occupational Safety and Health Act of 1970 and hcive been informed ofmy right to file a complaint with the 

nearest OSHA office. 

ACCEPTANCE OF CONTRACT Initials: 

f have been in.formed that the nurse registry is an equal employment opportunity employer that adheres to a 

policy of making employment and contractual relatioriship decisions without regard to race, color, sex, religion, 

national origin, handicap, marital status, or any other legally protected status. The nurse registry wlll comply, 

at all times, with Title VI ofthe Civil Rights Act of 1964, Section 504 of the Rehabilitation A_ct of 1973, the Age 

Discrimination Act of 1975, and all requirements imposed pursuant thereto; to the end that no person shall be 

discriminated against. My opportunity to contract with the nurse regfstry depends solely upon my 

qualifications and ability to petforrn the assigned job duties. The nurse regrstry's non-discrimination policy 

applies to clients, healthcare providers, and all personnel and independent contractors. 

I understand the nurse registry operates under the principles of affording equai opportunity for qualified 

handicapped inPividua!s, qualified veterans of the Vietnam era, and qualified disabled veterans. All applicants 

who believe themselves to be members of one or more of these groups, and who wish to identify themselves 

as such for the purpose of affirmative action consideration-are invited to do so. Submission of this fnformation 

is voluntary and refusal to provide it will not subject you to discharge or discipli_nary treatment. Information 

obtained concerning individuals shall be kept confidential, expect that {1} supervisors and managers may be 

informed regarding disabled veterans and handicapped individuals, (2) first aid and safety personnel may be 

informed as necessary, when and to the extent appropriate, if the condition rilight required emergency 

treatment, and (3) government officials investigating compliance will be informed. 

I wish to volunteer the following-information. I qualify under the followin_g (check one); 

U l do not qualify 

:., Handicapped 

I L ____ _ © 2014 Allianc:e Comulting Service~ of Florida, Inc. 

l 

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I 

LJ Vietnam Era Veteran 

IJ Disabled Veteran 

RECEIPTOFINFORMATION: .Initials·'"'< l/, 

I attest that l have been provided with information regarding the operation of this nurse registry applicable to 

my contractual obligation. This information included.a review of daily business operations, policy and 

procedure, dient services, documentation requirements, contractual obligations, arid the mission, vision, and 

values of the nurse registry. I have read and understand the policies and procedures of the nurse registry and 

have had the opportunity to have all ofmy concerns and/or questions resolved to my complete satisfaction. r 

understand that nurse registry policies and procedures, including personnel policies, may be modified and that 

they are not intended to.be a guarantee of my continued contractual relationship with the nurse registry. I will 

abide by alt policies at.all times and will not amend or compromise these policies under any c·1r:cumstances. I 

understand that failure to comply with nurse registry policy is grounds.for terminatioh of my contract with the 

nurse registry. 

TRANSPORTATION RESPONSIBILITY: lhitials:r #' ,,, \/ 

I attest that I have reliable transportation to be used for travel to and from client assignments. I further 

understand that 1 am responsible for maintaining and submitting p'roof of automobile insurance that minfmal!y 

meets state requirements for insurance, lf l intend to utilize my own vehicle as means for transportation. - RECEIPT OF PERSONAL PROTECTIVE EQUIPMENT: ' 

/ understand the hazards of my position with the nurse registry. t .attest that f have been properly instructed in 

the use of personal protective equipment (PP£} and that the nurse registry has supplied me with appropriate 

PPE, as applicable to my position with the nurse registry. I agree that, as a condition of my contract, I .im 

required to follow th_e established protocols for the use of PPE while providiryi client care and services. 

STATEMENT OF COMMITMENT: lnitia!s:r' V 

ln compliance with the nurse registry's policies and procedures, I agree to abide by the following guidelines: 

" r agree to wear my·identification during assignment. 

'" I will carry my professional license or certification with me at all times during working hours ata health 

care facility and agree to produce such a record for review by the health care facility, uppn request. 

• l wrn always maintain professionalism in the home to which I am referred or the facility or business to 

which I am -referred. 

• I will contact the nurse registry regarding an_y areas of discrepancy between the assignment and my 

ability to carry out that assignment (whether it ls in a private home or facility/agency}. I will also 

contact the nurse registry if l identify any discrepancy between the assignment and the care needs of 

the dient. 

'" 1 will not accept any money or gifts from the client/caregiver. I wli! receive payment for services· 

rendered directly from the nurse-registry and not from the clients to whom ·1 provide services. 

•11 I will notify the nurse registry if r am unable to arrive for my assignment at the .scheduled time or if I 

am unable to meet my assignment commitment. I understand that.the nurse registry wil! contact the 

client/caregiver or facility to make alternative arrangements. I also understand that not notifyillgthe 

nurse registry is grounds for termination ofmy contract. 

,11 ! will not make or accept personal telephone calls at the client's home. l, 

e I will.not smoke at the client's home. 

'" I will not send anyone else to the client's home to complete my assignment and I will not take anyone 

with me to the client's home to assist me in completing my assignment. I acknowledge that violation 

of this policy is groUndsfor termination of my contract, 

41 ! wm accept assignments on a case-by-case basis and I may accept or reject any assignment offered by 

© 2014 Alliaf,ce Consulting.S~rvice~ of Florida, !nc. I '----'-----~----------,"_, __ --'J 

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the nurse registry .. Once I accept an.assignment, I am obligated to fulfill that assignment. 

• i will provide care in a mannerthat does not discriminate against dients on the basis of race, color, 

national origfn, handicap, age, or any other legally protected status. 

a l will complete and submit all documentation per nurse registry policy. I understand the nurse registry 

may withhold payment if documentation pertaining to the services I have provided is not accurate and 

completed in a timely manner. 

0 l understand that habitual tardiness, excessive cancellations, and failure to report to ·an assignment are 

cause for the termination of my contract with the nurse registry. 

VISIT NOTES POLICY: lnitialst/.1..,.. 1 / 

I understand that it is nurse registry policy for visit notes and all other documentation fora client's file to be 

written and submitted to the Administrator weekly. I wm ensure complete, concise documentation as required 

per nurse registry policy and procedure and submit my visit notes on a weekly basis and on time. I understand 

th,;1t failure to do so will result in a delay in receiving_my paycheck and may result in other disCJpHnary action, 

up to and including terminatio_n of m'y contract. 

·COVENANT NOTTO COMPETE: Initials: r, ; 

During the term of my o:mtrac.twith the.nurse registry and for a period of at least one vearthereafter, I wm 

not contact a nurse registry client, directly or indirectly, either·for his/her own account or otherw1se;to be 

employed by, participate fn, consult with, perform services for, or otherwise be connected with any business 

the same as or similar to the business conducted by the nurse registry. l agree to notify the nurse registry in 

the event that a.client attempts to arrange for services directly with me. l agree not to accept assignment 

from any client of the nurse registry for a period ofat least one year following my separation from the nurse 

registry a.nd/or termination of my contract. In the. event of a breach, a threatened breach, and failure to 

comply with this section, the nurse registry shall be entitled to o!:,tain an injunction restraining the 

comniitments or continuance of the breach, as well as any other legal or equitable remedies :as permitted by 

law. 

SCHEDULED VISITS: Initials: t '~ Y II 

I have been informed that the continuity of client care is-of utmost importance and services must be provided 

in accordance with a client's plan of care. I acknowledge that I will provide services-to-clients e)(actly as they are 

assigned. I wm not let any assignment from this nurse registry overlap with those assigned ta me by other 

facilities or agencies and f will fulfill my responsibilities as directed. I understand that I work for the nurse 

registry as an independent contractor and that the clients I provide services to belong lo the nurse registry or 

facility to which I.am assigned. ! acknowledge that lam strictly prohibited from transferring or attempting to 

transfer any client case to another nurse registry, agency, or facility. 

CONFLICT OF INTEREST: Initials:/' J .r:: .// 

Elite Senior Management policy prohibits its c:ontractors from engaging in any activity, .practice or act which conflicts 

with or appears to conflict with the interest of the registry. lt i_s ltnposslble to describe all the situations, which inay 

cause or give·the appearance of a conflict of interest Therefore, the prohibitions included here irfthis policy are not 

exhaustive of all potential conflicts of interest. lt is the obligation of contractors to report any potential conflicts to 

supervisory staff. Contractors are not to engage in directly or indirectly in any conduct in which is disloyal 

disruptive, competitive, or damaging to the registry. Contractors are prohibited from accepting any employment 

wi"th any organization that does business with the Registry. 

© 2014 Alli an Ce Com;Ulting Services of Florida, Inc. 

. 

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I have read and understand the above information concerning the policies and procedures of the nurse registry. 

-agree to abide by the policies and procedures of the nurse registry,_ lnduding personnel policies, and have been 

informed that failure to do so may result in disciplinary-action up to and inducting termination of my contract . 

• 

.,,'5,3. 21 

Name (Please print} Signature Date 

© 2014 Alliance Consulting Services of Florida, Inc. 

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INDEPENDENT CONTRACTOR AGREEMENT 

This Independent can tractor agreement (hereinafter referred to as "the Agreement'') i~ade <!l1tj __ entered 

into-tfiis dayi £i • :3 .., :Z~ I , by and between ALL Vf P CARE, !NC. a Florida 

corporation qncJ licensed nurse registry {hereinafter referred to as "Company"), and 

:.JG "2,,, . • -· • ,1:y;.~ . • o 

WHEREAS, "Nurse registry," per400_462(21J, F_s., means any person that procures, offers, promises, or 

attempts to secure heali:hcare-related contracts for registered nurses, licensed practical nurses, certified 

nursing assistants, home health aides, companions, or homemakers, who are compensated by-fees as 

independent contractors, including, but not limited to, contracts-forthe provision of services to clients and 

contracts to provide private duty or staffing services to health care facilities licensed under chapter 395 or 

this chapter or other business entities, 

WHEREAS, "Staffing services," per 400.462 (29) F.S., means senrices provided to a h_ealth care facility, school, 

or other business entity on a temporary or school-year basis pursuant to a written contract by licensed health 

care personnel and by certified nursing assistants and home health aides who.are employed by, or Work 

underthe auspices of, a licensed home health agency or who are registered with a licensed nurse registry. 

WHEREAS, Company desires to contract with said Contractor to perform services in acccirdan·ce with the 

terms of this Agreement. 

WHEREAS, Company hereby contracts with Contractor to fulfill the following indicated positron as an 

independent contractor of the nurse registry: 

__ Registered. Nurse 

_lj:ensed Practica'I Nurse 

-.0Jome Health ·Aide 

__ Certified Nursing Assistant 

__ Homemaker/Compa:nion 

NOW, THEREFORE, in consideration of these premises, mutual· promises, c_ovenants terms and condtt:ions 

contained hefeih, and-other good and valuable considerations, the parties acknowledge the. receipt and 

sufficiency of which,. the parties agree as follows: 

CONTRACTOR APPOINTMENT 

Said duties wllt be carried out in accordance with all applicable law and regulation as weli as applicable nurse 

reglstry policy and procedure. Job respo_nsibilities are speclfled In Contractor's job description for the 

position indicated above. Contraμor must continually meet all personnel qualifications, as set forth in said 

job description as well as applicable state and federal law and regulation. Contractor does here.by attest that 

he/she is licensed or certified in the State of Florida (if required for the position) and that he/she shall notify 

Company of any change, modification, dlsciplfnary action or any ev.ent th.at may otherwise affect the validity, 

active status, or impair in any manner the underlying license or certification of said Contractor. Contractor 

hereby accepts such appointment and is wilHng to perform these services iii accordance with the terms 

hereinafter set forth. Colitractor shall provide setvices to dients·in private homes or healthcare facilities, 

agencies or other organizatlons to whlth the registry refers the services of Contractor at such times and at 

such places specified by Company in its relationships with 'those individuals or organizations. 

© 2014AU\ance Consulting Services of Florid.a, Jnc_ 

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SERVICES OVERSIGHT-CONTRACTOR ANb COMPANY RESPONSIBILITIES 

Company·wHl retain and maintain all clinical records of dients to whom services are provided in their private 

homes. Services to b_e provided through a contractual relationship with another business entity or healthcare 

facility will be coordinated between Company and said entity in atcordance with registry policy and 

applicable law and regulation .govem'ing the provision of these services" Sertrlces wlll be properly coordinated 

by Contractor and/or the supenrisocor designee. Contractor's services·wUJ be provided in accordance with 

t_he client's Plan of Care {hereinafter referred to as 'POC') and Company is responsible for the scheduling of 

home visits and periodic client' evaluation according to the client's POC, when appliCable. Referrals will be 

given to contractor in accordance with the duties Contractor Js !awfully allowed and competent to perform 

and for whkh the nurse registry is /Jcensed. Contractor is responsible for participating in a client's POC within 

the scope of his/her practice as defined by law and regulation and in accordance with nurse registry policy 

and procedure as wefl as the polic_ies.of the entity to which Contractor may be referred. Company will use 

Contractor when company deems It necessary and in its sole discretion determines that the skills and 

qualifications of Contrar:tor are appropriate to meet client care needs and will provide those services 

acr:ording to the schedule set forth and authorizr,d by Company. Both Company and Contractor agree that 

the Company (in conjunction with healthcare entities to which the Contractor is referred) will also coo,rdinate 

client assessments, reassessments, formulation and revision of plans and discharge plannfng, the schedule 

for home visits, supervision, and .case management. Contractor shall participate wlth Company in these 

activities as qualified and appropr"rate to his/her position and professional privileges. 

CONTRACTOR'S REPRESENTATION 

Contractor represents to Company that Co'ntractor is, and will continue to be during the term of this 

Agreement, duly licensed as necessary in the State of Florida to provide the services hereunder, and the 

execution of this Agreement by the Contractor does not conflict with any other agreement to which the 

Contractor is a party. Contractor also represents that Contractor wiH perform hereunder without negligence 

and ln compliance with all appli"cab!e Jaws including, wWiout limitatlon, professional regulations. Contractor 

will dress appropriately while provlding·services and comply with registry pd[fcies. 

TAX LIABILITY 

Company shall ilot be liable for withholdfng any tax, ·social security taxes, worker's compensation or other 

expense or liabillty attributable to an employer/independent contractor relationship. Contractor agrees to 

accept responsibility for the payment ofSelf~emp!oymenttaxes, as applicable and in accordance with state 

and fed era! law. Contractor accepts responsiblrrty for applicable state and federal ta>1es, such as Social 

Ser:urity. Contractor also acknowledges that he/she will receive an IRS Form 1099 for each year as a 

subcontractor ofthe registry. This form wil! be s~ntto the Internal Revenue Servfce (IRS} as we.IL 

CIVIL RIGHTS REQUIREMENTS 

Pursuant: to Chapter 760 F.S., Company is committed to compliance with civil rjghts requirements. As 

applicable to·operation of the nurse registry, Company complies with the provisions of Florida statutes 

concerning civil rights and anti-discrimination laws. 

Company Is an·equal employment opportunity employer that adheres to a policy of making employment and 

contract decisions without reg a-rd to race, color, sex,. religlon, national origin, handicap, marital status, or any 

other legally protected status. The nurse registry will comply, at alt times, with Title VI of the Civil Rights Act 

of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, .and all 

requirements Imposed pursuant thereto, to the end that no person shall be discriminated against. 

Contractor's op·portunity to contract with Campany depends solely up.on his/her qualifications and abilJtyto 

perform the assigned job duties. Company's non-dfsr:rtmination pol!cy applies to clients, healthcare 

providers, and alt personnel and 1ndependent·contractors. 

© 2011\ Alliani:~ Cons.ultirigServii:e& of Florida, !ni:. 

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I 

l 

RELATIONSHIP BETWEEN PARTIES 

Contrr.ictor is retained and contracting with Company only for the purposes and to the extent set forth in this 

Agreement and corresponding job description, and his/her relation to the Company and its ·subsldiary 

companies shall, dufing the psriod or periods of providing services hereunder, be that of an independent 

contractol,". Contractor shall not be considered as.bejng entitled to participate in any plans, arrangements, or 

distribution by the Company or lts subsidiary companies pe1taining to or in connection with any pension, 

stock, bonus, profit~sharing or similar benefits for their regular independent contractors. 

These parties acknowledge that neither Contractor nor Company, or any of their affiliates (induding, without 

limitation, prl'ndpals, employees, agents, and executive offfcers,-if anyl shall be deemed hereunder jolnt 

ventures, principals, partners, employees or agents of other party hereto, provided all of the duties, 

obligations and responsibilities of Contractor, and-all activities with respect to the satlsfactloli of the. 

foregoing, shall be conducted by Contractor of the foregoing, shall be conduc;ted by Contfactor-independent 

of Company as an independent·contractor. Contractor shall indemnify and hold the Company harmless from 

any and al/ claims of every kind and ·description whatsoever asserted against Company arising out of the 

performance by Contractor in his/her duties, obligations and responsibilities hereunder. Notwithstanding 

anything contained herein, Contractor shall not be permitted to delegate any of Contractor's duties 

hereunder to any employee, agent or other person without the written consent of Company. Contractor shall 

have-general control of Contractor's actiVitles with the right to exercise independent good Judgment as to the 

manner {but only as permitted hereunder) of setvicing clients, customers and otherwise carrying out the 

provisions of this Agreement. In acting as an independent contractor hereunder, Contractor shall be required 

to make: arrangements for insurance, licenses and-permits and for the payment of income taxes and social 

security taxes with regard to any. payments received by Contractor and Contractor's services, 

Contractor agrees and acknowledges that it will promptly notify Company, in writing, of any inquiries. 

investigations, complatnts, and any disciplinary actions taken by any entity based on Contractor's actions and 

inactions. Contractor hereby authorizes any entity regulating or supeivising Contractor to release to 

Company all information relating to such complaint or discipllnary action. Contractor also agrees to provide 

Compa·ny access, upon request, to Contractor's books, documents and record_s to verify the costs and 

reasonableness of the servlcesfumished. 

PAYMENT FOR SERVICES 

Both Company and Contractor agree that the Contractor shall be paid according to the attached, Appendix A. 

Contractor will submit to Company accurate and complete records of servfces provided and will be paid every 

other Friday only ff services were provided by Contractor, conditions for payment were met, and p_ayment is 

due. Documentation pertaining to the services provided must be comp!e'te per nurse registry policy, 

accurately reflectservices provided, and be turned into the nurse registry in. a timely manner. Contractor 

acknowledges that payment for services may be withheld if all conditions rega'rding serv'ices and 

documentation of service provision have not been met in accordance with registry policy. Both Company and 

Contractor agree not to charg_e any dientfor covered services and items and to ret_urn money incorrectly 

collected. 

Contractor shall not be entitled to any other compensation, and Contractor shaH not be entitled to receive 

any reimbursements for any costs or expenses incurred by Contractor. In connection with services provided, 

Conti-actor Shall prepare and provide Company, as may be reasonably requested, all.reasonable 

documentation of such services in order that Company, or any other entity designated by Company, any 

comply with appropriate Federal and State laws with respect to the reimbursement of Company, or such 

other entity, of the payments by Company to Contractor as compensation. 

© 1:014 Alliarice Consulting Services ofFloriila. Inc. 

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BACKGROUND-SCREENING 

All Contractors referred for assignments by nurse regfstries shall meet state of-Florida background screening 

requirements. 

Company must either terminate the emplayment or contract of any of its personnel found to b,;;. in 

nontompliance with the minimum standards for good moral character contained in this section or place 

Contractor ir1 a posltlqn for which background screening is not required unless the eniployee is granted an 

exemption from disqualification pursuanno s. 435.07. Any person who is required to undergo screening and 

who refuses to cooperate In such screening or refuses to submit the inf0rmati6n necessary to complete the 

screening, including fingerprints when required, shall be disqualified for employment or contract in such 

position or, if employed, shall be dismissed. 

PROFESSIONAL RESPONSIBILITY 

N0thil1g "in this Agreement shall be construed to interfere with or otherwise affect the rendering of services 

by Contractor in accordance with his/her independent and professional judgment. This Agreement sha:11 be 

subject to the rules and regulations of any and all professional organizations or associations to which 

Contractor may from time to time belong ahd the laws and regulations governing said practice in this State. 

Contractor shall be responsible for obtaining and maintaining appropriate levels of professional liabi!lty 

insurance if applicable to cover contractor's performance hereunder. Contractor is required to prov!de 

Campany a valid Certificate of Insurance reflecting professfonal liability Insurance coverage immediately upon 

the request of Company. In addition, Contractor fs -required to -maintain automobile liability and personal 

injury protection insurance and shall provide proof of such insurance to Company in the event that a personal 

vehicle is uti!iz.ed for transportation and Whene11erequested by Company. Contractor must immediately 

notify Company if Contractor's professional Hability, automobile or P!P insurance is terminated, expires or is 

reduced, whether the insurance cornpanyor Contractor initiated such action. 

Both parties agree that Contractor shall submit dinica! notes and progress notes to the Administrator of the 

reg'istrv or designee Weekly (for services provided in the week prior), and shall confonn to the prescribed 

.scheduling of visits and periodic client evaluation. All clients' health information must_ be maintained 

according-to federal privacy law ('H!PAA') requirements. 

Both parties agree that the Company shall reqi.le.st the evaluation of the Contractor's performance on an 

annual basis. ft is an expectation of the nurse registry that Contractor will be competent to perform his/her 

responsibillties in a safe manner and that skills and• education acquired elsewhere transfer competently into a 

client care setting. 

COVENANT NOT TO COMPETE 

During the term ofthis Agreement and for a period of at le_ast one year thereafter, Contractor .shall not 

contact a Company client, directly or iJ1directly, eitherfor his/her own account or otherwise; to be employed 

by, participate in, consult with, perform services for, or otherwise be connected with any business the same 

as·or similar to the business conducted by Company. Contractor agrees to notify Company in the event that a 

nurse registry client attempts to -arrange for servlces directly with Contractor. Contractor agrees.not to 

accept assignment fmm any client of the Company for .a period of at least one year following Contra_ctor's 

separation from Company and/or termination of this Agreement. In the event any of the provisions of this 

section are determined td be ;nvalid by reason of their•scope or duratldn, this section shall be deemed 

modified to the extent required to cure the inva!id1ty. 

© 2014Alliance Consulting Service~ r;,f Florida, Inc. 

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In the·event of a breach, a threatened breach, and failure to comply w!th this section, Company shall be 

entitled to obtain an injunction restraining the commitments or contlnuance oft.he breach, as well as any 

other legal or equitable remedies as permitted by law. 

All statistical, financial and personal data relating to the client which is confidential and which is dearly 

designated as,such will be ~pt in the strictest of confidence by Contractor and Company. Accordingly, 

Contractor agrees not to competewith company for those clients and legal entities Contractor has serviced 

un_derthis Agreement. Contractor acknowledges and agrees that infonnation concerning the clients, 

suppliers, office files, proced_ures and policies and other·aspects of the business of the Company is 

confidential, and in connection therewith, Contractor agrees not to -use of disclose any such informatiOn at 

anytime except as pemiltted under or as otherwise permitted in Writing by the Company. Contractor agrees 

to immediately surrender all such information in the possession or control of Contractor, including all 

reproductions thereof, upon qny-termination of this Agreement. Contractor hereby agrees and 

acknowledges that: {i) lhls section and each of Its provisions are reasonable as they relate to restrictions and 

limitations upon Contractor; (ii} Neither this Agreement nor this section will Operate as a bar to Contractor-·s 

sole means of support; (Hi) This section may be enforced by Company through the use of an injunction or any 

other equitable remedy given in the amount of the damages to company for a breach qfthis•.section, in 

addition to any other remedies C,ompany may have hereunder-or under law; [iv} Company shall be entrtled to 

reimbursement from Contractor's legal fees, costs and expenses incurred by Company through all appeals;-jf 

any, to enforce thls section; {v} This sectlon shall survive any termination of thfs Agreement; (vi) lf any 

provisions of this section is deemed unenforceable by a court of competent jurisdiction fo_r-Whatever reason, 

such tenn shall be substituted with such tenn of immediately lesser duration or effect which shall be deemed 

enforceable. 

SUSPENSION ANDT£RM1NATION 

This Agreement shall commence qs of the date first written• below and shall continue for successive one (1) 

year terms, unless sooner terminated as foHows: {il This Agreement can be terminated by either party'hereto 

upoh thirty (30) days written notice prior to the commencement of the successive one {1) year period; {ii) 

This Agreement may be terminated by Company at any time without notice in the event Contractor breaches 

any covenant or representation under this Agreement; {iv) This Agreement may be terminated at any time 

upon mutual written consent of the parti_es. 

THIRD PARTY ~ENEFICIARIES 

Th"ls Agreement has been entered into solely for the benefit ohhe parties hereto and ln no event whatsoever 

shaH any other party or parties be deemed a third party beneficiary or beneficiaries of the Agreement, 

MISCELLANEOUS 

Florida law shall govern this Agreement, with the sole venue for any action, suit or preceding arising 

hereunder Palm Beach County, Flprida. No amendment to or assignment of this Agreement will be valid 

unless.in writing and signed by the parties signing below. This Agreement may not be waived unless such 

waiver in writing and signed by the waivlng party. Each party acknowledges having bee11 represei:ited by 

independent !ega! couhsel in connection with this Agreement or having waived such right. This Agreement 

sets forth the entire. Agreement of the parties as to the·subject hereto and supersedes any prior Agreement. 

Each party will execute such reasonable documents -and take such reasonable action as may be reasonably 

requested to give effect to this Agreement. All costs and expenses of the parties in connection with this 

Agreement shall be borne by each such party incurring such costs and expenses. This Agreement may be 

executed in any number of counterparts. 

© 2014 Alliance ConsultingService5·of Florida, Inc. 

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l 

I 

EJ\ITIRE AGREEMENT 

The Agre_emen~ (including any attachments and amendments hereto} constitute the entire undemanding 

between the parties hereto and cancels and supersedes all prtor negotiations, understandings and 

agreements., r;iither writbm or oral, w!tli respect ta the sub!ect: matter hereof_ 

Agreement executed as of this dav~f?..,__·_3"'-•--'?=_,/ ________ _ 

All VIP CARE, INC. 

L, < f~ 

Si~~zed Company Representative 

Mame~ lfqn.qllz e~-z 

Title, typ;1 f Oak... 

Date, 5' /tjμf 

I 

lnde endent Contrarov: 

n 

• 

j 

Signature of Contractor 

Name, QJlvz__ Da, 0

c<2.l15, )/4'/4:z;,.·'es. 

Trtle, t,/H;-'"-/ H • 

© 2014Allfance Consulting Services of Florida, Inc.. 

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APPENDIX A: INDEPENDENT CONTRACTOR PAYMENT SCHEDULE 

PRIVATE CLIENT HOME-PER VISIT RATE: 

Sign Up/Initial Evaluation Recertification/ 

I> Visit Regular Client Visit Re-assessment or 

Discharge 

RN 

LPN 

REFERRAL TO FACILITY, AGENCY, OR HEALTHCARE ENfilY-PER VISIT RATE: 

Sign Up/Initial Evaluation Recertification/ 

Visit Regular Client Visit Re-assessment or 

Discharge 

RN 

LPN 

CLIENT VISITS TO PROVIDE SERVICES-PER HOUR RATE: 

Private Client Home Referral to Facility, Agency, or 

Healthcare Entity 

HHA/CNA 

Homemaker /Companion 

5 • 3- Z/ 

Date 

5- ?- 2-/ Contractor Signature Date 

••~s;,,{1-cy:= .5/tllz, I I Date 

<i:l 2014 Alliance Consulting Services of Florida, Inc. 

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AFFIDAVIT OF COMPLIANCE WITH 

Background Screening 

Requirements 

Authority: This form may be used by all employees to comply with: 

the attestation requirements of Sei;tion 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 appHcation for a health care proyjder J.icllllli, please attach a copy of the screening results and submit with the licensure application. 

Employee/Contractor Name: <E,i2...t.,1 z. .ba ;=' Q_Qf--r.c; y.,-9A, ,,, ,"as V 

Health Care Provider/ Employer Name: 

Address of HeaHh Care Provider: 

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: 

Crtmlnal offenses found in section 435.04. F.S 

(a) Section 393.135, relating to sexual mlsconcluct with 

certain developmentaBy disabled dients and reporting of 

such sexual misconduct. 

(b) Section 394.4593. relating to sexual miscoodud with 

certain mental health patients and reporting of such sexual 

misconduct. 

(c) Section illJ..11, relating to adult abuse, neglect, or 

exploitation of aged persons or disabled adults. 

(d) Section 782.04. relating to murder. 

(e) Section ZB2.07. 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 

chiid 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 

0) Section 784,03. relating to battery. if the victin of lhe 

offense was a minor. 

(k) Sectton 787 .01. relating to kidnapping. 

{I) Section 787.02. relating to false lmprisomienl 

(m) Section 787,025, relating to luring or enticing a child. 

AHCA Fonn # 3100-0008, September 2013 

Page 

Rule 59A-35.090 

1 of 3 Form available at: http:/lahca.myflorida.com/MCHQ/Central_Services/Background_Screening/1nfo1TT1ation_Resources shtml 

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{n) Section 787.Q.!(2), relating to taking, enticing, or 

removing a child beyond !he.state l!mlls with Criminal lnt,:.;nl 

pending custody proceedings. 

(o) Section 787.Q1(3), relating !o carrying a d1Ud beyon_d the 

state l!nes Witt) criminal infer1tto avoid produclt1g a child at a 

custody hearing or delivering the chiltl lo the designated 

person. 

(p) Section 790.115(1), relating to ellhibiling flrearms·or 

weapons wlth)n 1,000 feel of a school. 

(q) Sedfon,:i'90.115(2)fbJ, relating to possessing-an electric 

weapon ordev]c;e, destructive device, or other weapon on 

sc;hool property. 

(r) Se~on 794.011. re/a!lng to sexual batleiy. 

(s) Formers. 794.041, relafing to prohibited acts of p:,rsoru; 

ln familial or c;~slodial authorl!y. 

\lj Section 794.05, relating h un!awiul sexoa! activity wil!1 

r;srtaln mino15. 

(U) Chapter 7%, re/11ti119 to prostitution. 

{v) Section 798.0~, relating to lewtl and !:ascivfous behavior. 

(;w) Chapter 800, relallng lo !ewciness aild indecent 

exposure. 

{X) Section-806.bj, re!aling.tb arson. 

(:d Section 81D.D2, relating to burgla!',, 

(z) Seel/on 810.14. relating IQ voyeurism, if the offense ls a 

felony. 

(aa) Section 810.145, relating lo vfdeo Voyel!rism, if the 

offense is a felony. 

(bb) Chapter 812. relating to !heft, robbery, and relaled 

crirrtes, ff the offense ls a felony. 

{cc) Section 817.l;j63, rl"laling to fram!Ulent sale of controlled 

sul:lstances, only tfthe-0ffiinse was a felony. 

(dd} Section 825.102, relatlng lo abuse, aggravated abuse, 

or neglect ofan elderly person or disabled adult. 

(ee) Section 825.1025. relating lo lewd or rascMaus 

offenses committed up On rln !he presence of an elderly 

person ordls11bli;d adlllt. 

(ff! SecUon 825.103. rn!ating to expfottation of an elderly 

person or dtsabled adult, if the.offense was a felony. 

(gg) Section B26.04, relating to incest. 

(hh) Section 827.03 relating lo chlld abuse, 

aggravated Ghild abui;e, or neglect of a ct-~ltl 

(iij Section 827.04, relatjng lo con!r/but!ng to the 

delinque11cy ordependeni;y of a chnct, 

(jj) Fonner s. 827.05, relating to negligent treatmerit of 

.children. 

(kk) Section 827.071, reJa-ling to sexual perfonnance by a 

r.:hi!d. 

(Ill Section [!43.01 reJal;ing to resisting arrest With violence. 

{mm) Sectlan ~. rej,;ting to deprMng a Jaw 

enforcement, correction al. or c;ornlctional probation officer 

means of protection ar cornmun·itafion, 

(nn) Sei;Jlon 8-43.12. rel2ting to aiding In an escape. (oo)fll} 

(oo) Section 843.13'. relalir1g to aiding In the escape of 

juvenile inmates In correctional institutions. 

(pp} Ch,;.pter 847. relat'ing to obscene literature. 

(qqJ Section 874.05{1}. relating to enc;ourz.ging orrecrumfTfl 

ah_cthsr to jOin a crimln11! gang. 

(rr) Chapter 893, re!_ating to drug abuse prevention and 

control, only if the offense was 11 felony or ii any other pe.rson 

lnvalved in the offense Wils a minor. 

(ss} Section 916, 1075, relating to sexual misconductwflh 

c;erta1n forensic clienrs and reporting cf such. sexual 

misconduct. 

(It) Section 944.35(3), relating to inflicting cruel orlnhvman 

treatment o_n an inmate resulting in great bodily harm. 

{UU) Seefion ~' relafing lo escape!, 

(w) Section~:!!,.,. relating to harboring, concealing, or 

aiding.an escap..."'d prisoner. 

/ww) Sei;tion -944..47, relating to lntroduc\ion of ,;:ontraband 

into-a corraclionaf i'acilily. 

(XX) Secll□n 985.701, rela1ing to sexual mi5C:Onduct !n 

'ju~enUe justice programs. 

'(yy) Section 985.711, relatfng to contraband introd.uced Into 

detention fac1I1lies. 

(31 The securjty backgrounO Investigations under this 

sectlon must-ensure that no person subject 10 this section 

hss been round guilty of, regardless ofadju;:fication, or 

e11tered a plea of nolo contei'ldere or guilty t,:,, any offense 

that cons mutes domestic violence 11_sdaafinei:I ·rn s. 741.28, 

whether such act was committed ln this state or In another 

jurisdiction, 

AHCA Fonn # 3100-0008", Seplernber2013 , Rule 59A-35.090 

page 2 or 3 Form available at: httpJ!ahc:-a.myflorir:la, com/MCHQ/Cenlral_ Seivices/Background~Screeningf/nformat1on~ Resources.shtml 

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Criminal offenses found in sgction 40$.809(4), F.S 

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

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

(CJ Section 1Q_9.Q20, relating to Medkakf pn::t11ider fraud. 

\d} Section :!Q.9.fl20"1, relating to Medicaid fraud. 

(e) Seclion 741.28, relatii'Jg lo domestic violence. 

\f) Section 817.034, !'Elating to fraudulent acts througtJ 

mail. wire, radio, electromagnetic. photoelectronic, or 

photooplical systems. 

(g) Section 817.234, releting to false and fraudulent 

insurance dalms.• 

(h'J Se<:lion 817.505 relating \o patient brokering. 

(i) Section 81].568, relating to criminal use of personal 

ldenlilication information. 

(l) Secfion 817,60, relating to obtaining a credit card 

through fraudulent means. 

(k} Section 817.61 raJa!Jng to fraudulent use of credit 

catds, ff the offense w-as a felony. 

(I) Section $31-01, relating lo forgery. 

fm) Section !l3.LQ2, ratatil!g !{l uttering forged insl:rurnenls. 

\n) Section 831.07, relating !o forging bank bills, checks, 

drafts, er promissory notes. 

(o) Section 831 .09, relating to u11ering fo19ed bani\ bills. 

checks. drafls, or promisSory notes. 

(P) Section 33·, .30, relating to fraud 1n obiain'1ns med/clnal 

drugs. 

(ql Section~. relating to t~e sal€, manufacture, 

delivery, or possession Wi!h (he intent.Jo :sen, manuf.lcture, 

o_r de!Ner any counterfeit controlled subs(ance. lf !he ofumH! 

was a felony 

If you are also using this fon:n 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 

followinQ informafion. A copy of the prior screening results must be attached. 

Purpose of Prior Screenlng: __________ ~-------------

Screened conducted by: 

D Agency for Health Care Administration 

O Department of Health 

D Agency fut Persons with Disabilities 

0 Department of Children and Family Services 

O Department of Financial Services 

Affidavit 

Date of Prior Screening: ____ _ 

Under penalty of perjury, I, -----------~ hereby swear or affirm that I meet the 

requirements for qualifying for employment in regards to the background screening stand_ardset forth in 

Chapter435 and section 408,809, F.S. ln 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. 

'iit!e 

5 .?- 2-( Date 

AHCA F(lrm # 3100-DGOS, September 2013 

Page 3 of 3 Form aval!able 

Rule SSIA-35,090 

at '11tp:!fahca.myfl rida.corn/MCHQ/Central_Services/Sacf;.ground _ Screeningllnformation_ResourceS.shtml 

Case 0:22-cv-61553-WPD Document 62-4 Entered on FLSD Docket 07/18/2023 Page 19 of 25
llacKup withholding. Forind!vid11als. this is generally your Social security numbe~ (SSN). However, for a 

resident alien. sole proprietor, ordlsregardad entity. seethe Part I instructions on p.ige 3. For other 

entities. it is your employer iden!ilication number (EIN}. If you do not have a number, see How ro-gata 

TIN on page 3. o

I Employcrirlontifi<>atiwnumber _=:J Note. If 111eaccount ls ln more th.in one name. see the inslruciions for line 1 and.the chart on page 4 for 

guidelines on whose number Ip enter;. 

Certification 

Undar-penaltiE!S of perjury, I certify that: 

1. Toe number shown on this form ls my correct laxpayeridenliflcatlon number(or 1 am waitfng fora nurnber to ba 1ssued to me); and 

2. 

Service 

I am not 

~RS) 

subject to backup Wilhholdlng bec.,use: {a] I am exempt from backup withholding, oi"{b) t have not been nol!fred by the Internal Revenue 

that I am subject lo backup wllhholdfng as a 

no 

result of a· f.iilurafo report all interest or dividends, or(c) the JRS has notified mo that lam 

longer subject to backup witflho!ding·, and 

3. I am a U.S. clli.zen or other U.S, person (defined below); and 

4. lll'e FAT CA code(s) entered on this fonn (if any} indicating that lam eKempt from FATCA reporting is correct, 

Certification instructions. You must cross out item 2 above if you have been notified by (he IRS that you·are.currentJy Sllb]ectto backup Withholding 

lleca:use you have·failad to report all lnterestand dividends on your ta>: return. For real estatetransacl(ons, item 2 does notapj:,ly. For mortgage 

lnte~st paid. acqujsllion or abMdonrnent ot secured property, cance!tallon ot det:Jt, contributions to an ind!viuual rellre·menlarrangernent 

generally, paymenll> 

(!RA), and 

insln1c1ioris on page 

other 

3. 

than interest and dividends, you are no\ requii'ed to.sign tha certification, but you must prov1de·yourcorred TIN._See the 

General Instructions 

Ssmlqn roleleoces 11re :o 1he Internal Re~enue Code u,ilss-s olherv,j~e noled. 

Future developments. lnforrnaticin about de.:eroprmm\,; afre<:1ing form w.9 (such 

~~ lftOlS!alion enacted niter wetelea.e it) is at www.h-.9r:wHw9. 

Purpose of Form 

An lmli'/idua! or entity (fonn W-9 requaster) who is required lo file an information 

rotum with the ll'IS ml!$! oblain ycurcorrect !mmaye('identific,ition number rml) wtifch moy be your social secunly number (SSNI, indi;iduill lW<pay!lf' identification number (ITlN). adopHon taxpayer identITTc.:ilion r.umber (A11N). or emploY-..r 

"<di!nt@;at!on numb~r [EIN), IO reoort on-an ·,nto_nnal'mn return the arriount paldto yov, or other amount rnport,,blr:t on.an 1nfuJmation ralIJrn. Examples of lnformotkm rniuins includP.. but are nm lin1it!!d tc, the fol)owlng: 

• Form 1Q99•1NT ~nteres! earned or-paid) 

"Form 1099-DIVidivldends, in,::J~d,ng those from st<;,~ or mOJtual funds) 

• Fonn 10!!9-MISC (vario1l5 typw of income. po,:es_.,_,...,r,t,, orgrc~pruc~) 

• Form 1099-B {stock or mutual furld sales and c,,rtain oilier trnns~ctiO(I.~ l,y 

brokers) 

• form 109!1--S·(proceeds from real estate t<ansaclionS) 

• Fonn 10rul•k (me.chant card and tMird party networ.l\ transac:ion~) 

• Fom1 1098 (home mortgage im~rest), ·IOSB·I" (s1,1den! loan inler,as!j, 1tl9!!-T 1tuO!i<'1n) 

• Form 109!!.C (canceled cfubt) 

• Form 10S9·A (acqufsltion or abandonmBnl ot secured proparty) 

Use Farm W·9 only ~ycu "'" a u.s_ ~-a= (including a rasldent:aUenJ. mprovld" y,:rnr comai:t TIN. 

!fyau do ool rs/Um form W·9 to-Ifie requesrer vli/h a -nN, you mfghthe subject 

to backup wilhhnldfng. See-What is backup wifhhofding? Of1 page 2-

By signing the filled-out Form. you, 

1-C-Jrlil'/ !hat the "f1N you are 9i,•lng ;s com,,:;t (or.you <ITTl waltir,g for a number 

10 be ;ssu!>dJ, 

2. Cerlity1ha1 you are not $Ubj~.ci lo b,,,c1<up Witl•h!>ldtflg. er 

3. Cleim exemption from backUp\',1lhholdinglfyouarea U.S. exempt pay..e. If appf1cable, )'OU are also certifying !Mt a& a U.S. p..-sa·n, your allocable sh.1ra of 

<iny parlnershlp inGOme rrnm ;i U.S. lrade or businesi is not. sWlject t<.> the withl;oltflng Tll.,; on !oreign partners· .sha.-e of e!tecUvely ronnt'>Cted fnCCme. and 

4. Cert,fy tl1a1 FATCA cocle(sl ~ntered ,m thi,,"form fti any) indi<;:lllTngthat Y<JU are exempt Imm the fATCA reporting, is com,ct. s~e· Whal is FA1"C<I. rar:iorting? on 

pagrf2 fur further lnform~lion .. 

Cat. N<,: 10231X Form W-9 (Rev. 12·-2014) 

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HOME HEALTH AIDE/CERTIFIED NURSING ASSISTANT 

JOB DESCRIPTION 

REPORTS TO Administrator 

QUALIFICATIONS 

Licensed by the Florida Department of Health as a Certified Nursing Assistant, or for home 

health aides, documentation of succe._ssful completion of at least forty hours of training (content 

must be consistent wlth A orida regulations specific to home health aide training). 

Individuals who earn their CNA certificate in another state must contact the Florida Certified 

Nursing Assistant office at the Department of Health to inquire ·about taking the written 

examination prior to working as a.CNA in Florida. 

Registered nurses and licensed practical nurses who can show proof they are licensed in another 

State or in Florida can work as a home health aide in Florida. 

Home health .aides who complete thei'r training in another state must provide a copy of the 

course work and a copy of their training documentation to the nurse registry. Jf the course work 

is equlvalent to Florida's requirements, the nurse registry may refer the home health. aide for 

contract. 

Current CPR certification. 

Evfdence of continuing education as required. 

One {1)-year experience preferred. 

PRIMARY RESPONSIBILITIES (including but not limited to the following): 

" Fulfills assignments delei;:ated by the nurse registry and provides services In accordance With a 

client's service provision plan. 

" Meets all contractual obligations on an ongoing basis. 

a Performs al! personal care activities contained in a written assignment by a licensed health 

professional employee or contractor of the home health nurse registry and which includes 

assisting the client with personal hyg·1ene, ambulation, eating, dressing, shaving, physical 

transfer, and other duties as assigned. 

11 Provides assista_nce with ambulation, limited to providing·physica/ support to enable the ct!ent 

to move about within or outside of the c/fent's place of residence. Physical support includes 

holding the client's hand, elbow, under the arm, or hofdfng on to a support belt worn by the 

client to assist in providing stability or direct:ion while the client ambulates. 

" Provides as'sistance with bathing, limited to helping the client in and out of the· bathtub or 

shower, adjusting water temperatures, washing and drying portions of the body which are 

difficult for the dient to reach, and being_avaUable while the dient is bathing. Can also include 

washing and drying the client who is bed-bound. 

" Provides assistance with dressing, to inclu_de helping the client put on and remove clothing. 

u Helps the client with shaving and with oral, hair, skin and na11 care. (Nail trimming not allowed). 

11 Assists with toileting, inducting reminding the client about using the toilet, assisting to the 

bathroom, helping to undress, positioning on the commode, and helping with related personal 

hygiene, including assist<mce With changing of an adult brief. Also includes assisting with 

positioning the client on the bedpan and helping with related personal hygiene. 

" Provides assistance with physical transfer. Providing verbal and physical cueing, physlcal 

asSistance, or both while the client moves from one position to another, for example between 

th_e following: a bed, chair, wheelchair, commode, bathtub or shower, Or a standing position. 

Transfer can also include use of a mechanical lift, if a home health aide or CNA is trained in its 

© 2014All>ana:- Consulting Set\tltes of Florida. Inc. 

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use. 

n Maintains a clean, safe and healthy environment, which may indude light cleaning and 

straightening of the bathroom, straightening the sleeping and liVing areas, washing the dient's 

dishes orfaundry, and such tasks·to maintain ·cleanliness and safety for the client. 

11 Responsible for observing appearance and gross behavioral changes lo the clien.t and reporting 

these changes to the caregiver and the nurse registry or the registered nurse responsibre 

assessing the 

for 

case when giving care in the home or to the responsible facillty employee if 

staffing in a facility. 

" 

hurse registry on a 

Documents services provided to the dient or client and for filing said documentation with the 

regula, basis. 

" Performs other activities as taught and documented by a registered nurse, concerning_ ·activities 

fora specific client and restricted to the following: 

., Assisting-with the change ofa Colostomy ba~, reinforcement of dressing; 

~ ASsisting with the use of devices for aid to daily living such as a wheelchair or walker; 

• 

• 

• 

• 

Assisting with prescribed range of motion exercises; 

Assisting with prescribed ice cap or collar; 

Doing simple urine tests for sugar, acetone or albumin; 

Measuring and preparing spedal diets; 

Teaching housello!d routine. and skills to well members of the family; 

Measuring intake and output of fluids; 

" Measuringtemperature, pulse, respiration or blooQ pressure; 

" Keeping records of personal health care activities; 

11 Assisting with ADL'.s and !AOL's; 

'" Providing nutritional support. 

"' Provides assistance with a client';; self administration of medication, including the following: 

11 Taking the medication in its previously dispensed, properly labeled contafner, from 

where it is stored and bringing itto the client. 

0 Jn the presence of the client, reading-the label, operiingthe container, removing a 

prescribed amount of medication from the container, and dosing the container. 

" Placing an oral dosage ln the client's hand Or placing the dosage in another container 

and helping the client by lifting the container to his or her mouth. 

.. Applying topical medications. 

" Returning the medication container to proper storage. 

ra Keeping a record of when a client receives assistance with-self-administration of 

medication. 

"' Assistance with a client's self-administration of medication does not include the following: 

"' Mixing, compol,lnding, converting, or calculating medication doses, except for measuring 

a prescribed amount of liquid doses, except for-measuring a prescribed 

medication 

amount of liquid 

or breaking a scored tablet or cru_sh'mg atablet as prescribed. 

" The preparation of syril'lges for injection or the.admiriistration of medications by 

injectable route. 

"' Administration of medications through intermittent positive pressure breathing 

machines ora nebulfzer. 

a Administration of medlcations by way of a tube inserted in a cavity of the body. (e) 

Administration of parenteral preparatior:rs. 

11 Irrigations for debriding agents used in the treatment of a skin condition. 

11 Rectal, urethra!,,orvaginal preparations. 

© 2014Alf!am:e consu!tlog Services af Florida, loc. 

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! 

n Medications ordered by the physician or healtl') care professional with prescriptive 

authority to be given "as needed", unless the order is written with specific parameters 

that predude independent Judgment on the part of the unlicensed person, and at the 

request ofa competent dient. 

11 Medication for which the time of administration, the amount, the strength of dosage, 

the method of administration, or the reason for administration requires judgment or 

discretion on the part of the unlicensed person. 

1.1 The home health aide and CNA may also provide the following assistance with self-administered 

medication, as needed by the dierit: 

., Prepare necessary items such as juice, water, cups, or spoons to assist the client in the 

self-adminjstration of medication; 

" Open and dose the rnedicati.on container or tear the foil of prepackaged medications; 

11 Assist the resident in the self-admfnistration process. Examples of such assistance 

include the steadying of the arm, hand, or other parts of the client's body so as to allow 

the self-administration of medication; 

a Assist the client by placing unused doses of solid medication back into the medication 

container . 

., The home health aide or CNA may not change sterile dressings, irrigate body cavities such as 

giving an enema, irrigate a colostomy or wound, perform a gastric frrigation or enteral feeding, 

catheterize a client, administer medication, apply heat by any method, care fora tracheotomy 

tube, nor provide any personal health service which has not been included in the service 

provision plan. 

11 Adheres to-standard precautions. 

" Additional duties as assigned. 

,. _Abides by1;he registry's Code of Conduct. 

r.i Maintains client confidentiality per registry policy and federal privacy laws regardingthe use and 

disdosure of client's prot_ected health information. 

By my signature below, 

~ 

l acknoWledge and-accept the responslbilities of this position. 

'('' Signature'---~-~'.._,._"\...F~lli~~~.,\c-'~;_' ___ _ 

© 2014AUiance Crinsu!tlng Seruices cf Florida. !nc. 

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WADI/Bl OF PROFESSIOI\IAL LIABILll'V 1I\ISURAIIICE 

I,----===------~ have chosen not to carry a professional liability (prfr,tnameJ 

insurance policy while working as an independent contractorforthe registry, I agree to hold 

ha'rmless and indemnify ALL VIP CARE, INC. from any and all 

claims made against me in the course of performing the professional responsibilities assigned 

to me while under contract with the organizations or clients to.which I am referred to provide 

servlces. I understand the potential consequences of not carrying a professional liability 

insurance policy and agree to notify registry management if I decide to 

carry a poffcy in the future. 

Independent Contracto,

~.o_U. 0 ALL VlP CARE, INC'. 

Signature of lndependei\t Contractor 

l\lame, ClI:0 2 J)d:'artfu; 

Title: ,L/// M 

//Jllc/,'j,,/.c150 Name:. _ _,'.fj__,C,=(/c,ti,,1~•-"·z ___ _,_P<:,_ft?-'-'-' ... 2==·-

Title:_· _ _,_&_,_,,""/)'"'f-~Pc...,ae .. ,;,__/l:_ _ 

Date:._';2<-;,/'-q-'-'--/7.-~/ ___ _ 

© 2014Alliance Consu!tlngServic:es of Florida, Inc.. 

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AIIV C ar-e, I nc~ 

11

H ome C are B'=gins Here!" 

INDEPENDENT CONTRACTOR 

PROFESSIONAL LIABILITY POLICY 

Effective immediately, Independent Contractors on the Agency's roster must carry 

"Professional Liability." In addition, the Professional Liability must include All VIP 

Care, Inc. as an additional insured. 

The Independent Contractor can call CM&F Group, Inc. at 212/233-8911 to inquire 

about obtaining a policy and request to add All VIP Care, Inc. as an "Additional 

Insured." The Independent Contractor has the right to choose their insurance provider. 

If the Independent Contractor wants the Agency to purchase the policy, then the 

contractor must sign this form. 

which is to include All VIP Care, Inc. as an additional insured; and, I will 

By signing below, L <lJZ..v2- Lk:-1 te2elzs k/p-t>/ :~n(~~Professional Liability 

Agency when the policy has expired and/ or about to renew. 

contact the 

Furthermore, if the Agency purchases the policy on my behalf, I understand and agree 

that the cost will be deducted from my first pay-check. 

Independent Contractor Signature 

All VIP Care, Inc. Representative 

C: File 

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