Logo
Help

Application

*
*
*
*
*
*
*
*
*
*
*
*
*

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

AVAILABILITY AGREEMENT

1. I am available to work as follows: (if offered a case with in 1.5 hours travel and you do not accept, this is considered case refusal. 3 case refusals in a 30 day period will result in disciplinary action up to and including discharge)

Caregiver Preferences : Used for Scheduling

Patient/Smoker 12 Hrs Day Shift 12 Hrs Night Shift
Bed Bound Patient Bronx Brooklyn
Has Pet Allergies Live-In Manhattan
Nassau Short Hours Queens
Shabbat Observant Patient Transfers-Hoyer Lift Staten Island
Suffolk County Weekends Westchester County
Rockland County Orange County Sullivan County
Ulster County Dutchess County

Language Preference

2. Availability:

Saturday Sunday Monday Tuesday Wednesday Thursday Friday
to
to
to
to
to
to
to
Live in Live in Live in Live in Live in Live in Live in

3. * I am aware that I must be available to work all of the five (5) major holidays, which includes, Thanksgiving, Christmas and New Year’s Day, Independence Day, and Labor Day, based on Agency’s needs.

4. I understand that it is a requirement for all HHA/PCA’s employed by Preferred Home Care to be available to work a minimum of four weekend days per month. I am available to work:

  • Every Weekend
  • Every Saturday
  • Every Sunday
  • Every Other Weekend

5. *I am available to start working:

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 hours of work as caregiver’s request. In order for HHA’s/PCA’s to remain in “ACTIVE” status the caregivers must work/provide service hours to patients continuously during employment. HHA/PCA’s that do not provide service hours for a period of 90 consecutive days will 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 requests cases to ensure the HHA/PCA is not terminated due to 90 consecutive days of not working for the agency.

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

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

Home Health Aide Acknowledgment of Outside
Employment Attestation Form:

All Preferred Home Care of New York personnel are required to follow the Rule of Conduct and avoid actions that result in conflict of interest.

*
(Day of the week)
(Day of the week)

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.

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

*Date

FOR OFFICE USE ONLY

I authorize the above named individual / company to provide reference information.



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

Date