ORCA BUSINESS CARDHOLDER RULES OF USE

Transcription

1 ORCA BUSINESS CARDHOLDER RULES OF USE I agree to have $20.52 per month deducted from my paycheck each month. I understand that this deduction will be split between the first two paychecks of each month. As a Business Account Cardholder, I agree to the following: 1. I will use my ORCA Business Card for my own transportation only. I will not transfer my ORCA Business Card to any other person. I understand that my ORCA Business Card and any products will be blocked from further use if I misuse this benefit. 2. I will keep my ORCA Business Card secure and in good condition. I will immediately report a lost, stolen, or damaged ORCA Business Card to my company Transportation Coordinator. I understand a lost ORCA Business Card will be replaced only once per year at a charge of $ A defective ORCA Business Card will be replaced free of charge. 3. I will return my ORCA Business Card upon request or when I leave my employment with this company. If I do not return my ORCA Business Card, I understand that it may be blocked for further use on transportation services provided me by my employer. 4. I understand that the ORCA Business Card is valid for the following services provided by my employer: A. 100% of transit fares on regularly scheduled transportation service on King County Metro Transit, Community Transit, Everett Transit, Kitsap Transit, Pierce Transit, and Sound Transit B. Up to 100% subsidy for vanpool fares on participating transit agencies. C. Up to 100% subsidy for vanshare/vanlink fares on participating transit agencies. D. I understand that the ORCA Business Card products are not valid fare payment for services on any non-participating ORCA agencies and that I am responsible for gaining that information from my employer prior to card usage. 5. I understand that I am responsible to pay additional fares required for services not covered, or not fully covered, by my employer provided benefits. 6. I understand that any additional ORCA Products I load onto my ORCA Business Card become the property of my employer, and any refund of such products will be made by my employer according to its refund policy. 7. I understand the ORCA system will record data each time I use my ORCA Business Card. Data will include the date, time and location of the card when it is presented. I understand this data is owned by the ORCA Agencies and is accessible to my employer. I acknowledge the receipt of my ORCA Business Card, and understand and agree to the terms stated above on using the ORCA Business Card. Employee s Signature Date Employee s Printed Name ORCA Card Serial # Transportation Coordinator Use Only ORCA Card: Returned/ Lost/ Stolen Employee s Signature Date ORCA Card Serial

2 Employee#: DirectDeposit AuthorizationForm DirectDepositisamandatoryrequirementofemployment.Pleasecompletethefollowingformandattachavoided checkforeachaccount.ifyouhavequestionspleasecall orextension AuthorizingInformation TypeofAccount: BankName: CheckingAccount RoutingNumber: SavingsAccount AccountNumber: SelectOne: FixedAmount$ FixedPercentage %(100%goesifhereifyouwantallofyourpaycheckinthisoneaccount) Remainder TypeofAccount: BankName: CheckingAccount RoutingNumber: SavingsAccount AccountNumber: SelectOne: FixedAmount$ FixedPercentage %(100%goesifhereifyouwantallofyourpaycheckinthisoneaccount) Remainder TAPEVOIDEDCHECKHEREIFAVAILABLE (pleasedonotstaple) AuthorizationSignature IherbyauthorizeProvidenceHealth&Servicestomakepayrolldepositstomybankaccountindicatedontheattached I hereby authorize Swedish to make payroll deposits to my bank account indicated on the attached VOIDED CHECK VOIDEDCHECK(depositslipwillonlybeacceptedforasavingsaccount).Theeffectivedateforthedirectdepositwillbe (deposit slip will only be accepted for a savings account). The effective date for the direct deposit will be approximately approximatelyonemonthfromthereceiptofthisauthorization. one month from the receipt of this authorization. YoucanupdateorchangeyourdirectdepositinformationviaEmployeeSelfService(ESS)atanytime. EmployeeName(pleaseprint)EmployeeSignatureDate Please return form to: Fax: or PHSImageNowHRSwedish@providence.org 00-Direct Deposit

3 HIPAA TRAINING ACKNOWLEDGEMENT FORM I acknowledge that I have received, read and taken the written exam in the HIPAA Training Handbook provided to me by Minor & James Medical Clinic to comply with the mandatory training requirement effective April 14, Employee Signature Print Name Human Resources Signature Date HR Forms 7/8/08

4 MANDATORY EMPLOYER REPORTING PROGRAMS REPORT FORM EMPLOYER IDENTIFICATION EMPLOYER NAME Minor & James Medical, PLLC EMPLOYER ADDRESS 515 Minor AVE #200 CITY Seattle EMPLOYER FEDERAL ID NUMBER STATE WA ZIP EMPLOYEE IDENTIFICATION FIRST NAME MIDDLE NAME LAST NAME EMPLOYEE ADDRESS CITY STATE ZIP SOCIAL SECURITY NUMBER DATE OF BIRTH REPORTING AGENCIES EXCLUDED PARTIES LIST SYSTEM FEDERAL FINANCIAL AND NON- FINANCIAL ASSISTANT AND BENEFITS ENTERED BY: DATE: DEPARTMENT OF HUMAN AND HEALTH SERVICES FRAUD PROTECTION AND DETECTION ENTERED BY: DATE: DEPARTMENT OF SOCIAL AND HEALTH SERVICES NEW HIRE REPORTING ENTERED BY: DATE: HR/Forms/Mandatory Employer Reporting Programs Report Form Rev

5 HEPATITIS B VACCINATION EMPLOYEE CONSENT This form applies to the following departments: Ancillary Clinical Staff Laboratory Office Assistants Physicians Radiology Research Materials Management Name: Hire Date: Department: Supervisor: Birth Date: Job Title: Location: I have been previously immunized. I started the series but have only had to finish the series. Date of last dose: Date: of the three doses and would like I would like to be immunized. I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring the hepatitis B virus. I understand I will receive the hepatitis B vaccine, at no charge to myself. I decline Hepatitis B vaccination at this time. I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring the hepatitis B virus. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine, at no charge to myself. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and want to be vaccinated with Hepatitis B vaccine, I can receive the vaccine series at no charge to myself. Employee Signature Date Witness HEALTH QUESTIONNAIRE If consented for the vaccine: YES* NO Have you ever had a serious allergic reaction to Thimersal (an ingredient found in contact lens solution) or a previous dose of Hepatitis B Vaccine? *If yes, you cannot receive the Hepatitis B vaccine through this program Do you have a moderate or severe acute illness? *If yes, you will need to wait until you are well to receive the Hepatitis B vaccine. See back for vaccination record Hepatitis B Employee Consent Documents/Candidate Files File in Employee Health File 2/07 Page 1

6 HEPATITIS B VACCINATION RECORD I have been informed of the risk and benefits of receiving the Hepatitis B vaccine and have received, read and understand the Vaccine Information sheet. Date of Publication: Employee Signature: Date: 1 st Dose Date: Given By: Lot#: 2 nd Dose 3 rd Dose Date: Given By: Lot#: 2 nd dose must be given at least one month after the 1 st dose Date: Given By: Lot#: 3 rd dose must be given at least 2 months after the 2 nd dose and at least 4 months after the 1 st. It is recommended that Heath Care Workers be tested for a definitive immunity to Hepatitis B following the vaccination. A titer to test for AntiHBs should be drawn between 1-2 months after completion of the series. This will be done at no charge to the employee. Date: Titer results*: *AntiHBs levels of 10mIU/ml by RIA or positive by EIA indicate immunity to hepatitis B. Comments: Hepatitis B Employee Consent Documents/Candidate Files File in Employee Health File 2/07 Page 2

7 PERSONAL PHYSICIAN STATEMENT Name: Date: Social Security #: DOB: Physician Name: Type of Screening: New Employee Annual Occupational Exposure The above individual, an employee of Minor & James, requires further evaluation of his/her TB status due to: Current PPD screen result of 10mm or greater or repeated test of 5mm or greater States signs and symptom consistent with TB on current TB Questionnaire States previous positive PPD test and requires documentation of test results and evaluation Employees TB Questionnaire and/or PPD results attached. Yes No Please fill out the following sections and return, with any other information (copy of CXR results, etc.) to Minor & James Medical, ATTN: Safety Officer ( x3840) as soon as possible. Thank you. The above employee (check all that apply): Recommendations: Has been evaluated for clinically active and latent TB Requires a chest x-ray Has clinically active TB Has latent TB disease Has received or is receiving preventative therapy according to CDC guidelines Is receiving treatment for active TB Physician signature: Date Tuberculosis Prevention Plan 8/08 Personal Physician Statement File in Employee Health File

8 MINOR & JAMES MEDICAL, PLLC TUBERCULOSIS PREVENTION PROGRAM PRE-SCREEN QUESTIONNAIRE CONFIDENTIAL Name: Hire Date: Department: Supervisor: Birth date: Job Title: Location: 1. Have you had a Tuberculin Skin Test or PPD in the last 12 months? Yes Date of test: ** Result: Negative Positive Unknown No Unknown 2. Have you been given a live vaccine (i.e. MMR, Oral Polio, Yellow Fever) in the last 4 weeks? Yes Date of vaccine: ** No Unknown 3. Have you ever had a positive Tuberculin Skin Test or PPD before? Yes Date of test: No Unknown 4. Were you born in the United States? Yes No Country of birth: Unknown 5. Have you traveled or lived outside the US in the last 2 years? Yes Country traveled/lived No Unknown 6. Have you ever received BCG vaccine? (BCG is a vaccine used to prevent TB) Yes Date of vaccine: ** No Unknown Tuberculosis Prevention Plan 1 Pre-Screen File in Employee Health File 10/05

9 MINOR & JAMES MEDICAL, PLLC TUBERCULOSIS PREVENTION PROGRAM PRE-SCREEN QUESTIONNAIRE CONFIDENTIAL 7. Have you ever had a chest x-ray? Yes Date of chest x-ray: ** No Results: Negative Positive Unknown Unknown 8. Have you ever been treated for TB disease? Yes Date of treatment: ** Type of treatment: ** No Unknown 9. Have you ever had any of the following symptoms for more than 3 weeks at a time: (Please check all that apply) Excessive night sweats Persistent fever Excessive fatigue Persistent coughing Hoarseness Coughing up blood Excessive weight loss ** Please provide documentation to the Safety Office within 2 weeks. Type of Screening: STOP PPD Tuberculin Skin Testing New Employee with Documented Negative in Past 12 Months New Employee w/o Documented Negative in Past 12 Months Instructions: 1. If the employee has had a live vaccine in the last 4 weeks delay testing for 4 weeks. 2. Give one-tenth millimeter of PPD (5TU) injected intracutaneously to left arm. A wheal, 6-10mm in diameter, should be produced. 3. Do not cover site with a band aid or apply pressure. 4. PPD test results should be read between hours after injection by designated staff. 5. Result is based on the presence or absence of an induration (firm, palpable swelling) at the injection site. Disregard redness or erythema. Measure induration in mm s. 6. Record the readings below according to the chart and document action if indicated. Send test results to Safety Officer. 7. Fill out Facility Record and give employee the Employee Record section. 8. If referred to their personal physician, give employee a copy of this result form and a Personal Physician Statement form with reason checked off. Employee MUST be seen by their physician within 2 weeks and bring both forms, signed, to the Safety Officer. FOR QUESTIONS CALL: SAFETY x 688 Tuberculosis Prevention Plan 2 Pre-Screen File in Employee Health File 10/05

10 MINOR & JAMES MEDICAL, PLLC TUBERCULOSIS PREVENTION PROGRAM PRE-SCREEN QUESTIONNAIRE CONFIDENTIAL INDURATION RESULTS ACTION INITIAL REACTION IS: 0-4mm INITIAL REACTION IS: 5-9mm NEGATIVE DOUBTFUL REPEAT TEST FOR EMPLOYEE W/O DOCUMENTED NEGATIVE IN PAST 12 MONTHS (FLOWCHART 1) NONE FOR EMPLOYEE WITH DOCUMENTED NEGATIVE IN PAST 12 MONTHS (FLOWCHART 2) REPEAT TEST IN 1-2 WEEKS (FLOWCHART 1 or 2) REPEATED REACTION IS: 0-4mm NEGATIVE NONE REPEATED REACTION IS: 5-9mm INITIAL OR REPEATED REACTION IS: 10mm OR MORE POSITIVE IF FIRST TEST WAS 5-9mm DOUBTFUL IF FIRST TEST WAS 0-4mm POSITIVE REFER TO PERSONAL PHYSICIAN (FLOWCHART 1 or 2) REFER TO PERSONAL PHYSICIAN (FLOWCHART 1 or 2) ATTACH SKIN TESTING RECORD CARD HERE Actions: 1 st Reading: mm Action: None Repeat test Referred to Personal Physician 2 nd Reading: mm Action: None Referred to Personal Physician Employee Signature (once results are read) Tuberculosis Prevention Plan 3 Pre-Screen File in Employee Health File 10/05

11 MINOR & JAMES MEDICAL, PLLC TUBERCULOSIS PREVENTION PROGRAM PRE-SCREEN QUESTIONNAIRE CONFIDENTIAL THIS PAGE INTENTIONALLY LEFT BLANK Tuberculosis Prevention Plan 4 Pre-Screen File in Employee Health File 10/05

12 MINOR & JAMES MEDICAL, PLLC TUBERCULOSIS PREVENTION PROGRAM GET THE FACTS QUIZ This is a mandatory quiz for all new employees at Minor & James Medical, PLLC. Name: Hire Date: Department: Supervisor: Birth date: Job Title: Location: The answers are in the Tuberculosis: Get the Facts pamphlet. 1. The germs are put into the air when a person with TB of the lungs: 2. TB affects what other parts of the body? 3. A. General symptoms of TB may include: B. Symptoms of TB in the lungs may include: 4. Anyone can get TB. TRUE FALSE 5. High risk populations are: OVER Tuberculosis Prevention Plan 5 Pre-Screen File in Employee Health File 10/05

13 MINOR & JAMES MEDICAL, PLLC TUBERCULOSIS PREVENTION PROGRAM GET THE FACTS QUIZ 6. Match the following: TB disease TB infection A. The TB is active in their body. They have one or more of the symptoms of TB. Capable of infecting others. Medicines which can cure TB are prescribed for these people. B. They have the germ that causes TB in their body. They are not sick because the germ lies inactive in their body. These people may develop TB disease in the future, especially if they are in one of the high risk groups. Medicine is often prescribed for these people to prevent them from developing TB disease. 7. A negative test usually means the person is not infected except in cases of: A. If recent infected? TRUE FALSE B. If the person s immune system is not working properly? TRUE FALSE 8. A positive test usually means: A. The person has been infected with the TB germ? TRUE FALSE B. It means the person has TB disease? TRUE FALSE C. Other tests are required to confirm TB disease? TRUE FALSE Tuberculosis Prevention Plan 6 Pre-Screen File in Employee Health File 10/05