1.* I am available to work in the following areas:

    Brooklyn, NY
    Queens, NY
    Manhattan, NY
    Bronx, NY
    Nassau County
    Suffolk County
    Rockland County
    Orange County
    Westchester County

2.* I am able to speak the following languages:


3. *I can start working:

4. Can you work Live-In cases?

5. Are you willing to work with Covid positive patient?

6. Can you work on the weekends:

I understand Preferred Home Care may offer short hour assignments and will make every effort to offer additional short hour cases to provide caregivers with total hours of work at caregiver’s request. In order for HHA’s/PCA’s to remain in ACTIVE status, caregivers must work/provide service hours to patients continuously during employment. HHA’s/PCA’s that do not provide service hours for a period of 120 days may be terminated. I further understand that declining/refusing more than three cases in 30 day period may result in disciplinary action up to and including discharge. It is the responsibility of the HHA/PCA to communicate with the agency regarding changes to availability and to request cases to ensure compliance. I am aware that I cannot and will not work for other Licensed or Certified Home Care Agencies or any other organization during the hours that I am assigned to provide home health aide services to a patient of Preferred Home Care of New York.

* I have read, understand, and agree to abide by the complete agreement.

By signing below I acknowledge that all the information provided above is true and accurate. I further acknowledge my understanding of the terms and conditions listed above.

* Please sign with-in the signature pad highlighted in yellow below.

Social Security Card
Form of ID
Chest X-ray required if positive