Healthcare Caregivers Search

HEALTHCARE CAREGIVERS SEARCH

Patient Information

Client Name:

Date of Birth:    Gender:

Insurance & Primary Coverage

Medical History & Current Status

Care Needs & Search Criteria

Type of care required (check all that apply):

Personal care (bathing, dressing)
Companion care / supervision
Medication administration
Wound care / dressing changes
Mobility assistance / transfers
Dementia / memory care
Skilled nursing tasks (RN/LPN)

Desired start date:    Duration:

Frequency: Daily Weekly As needed Live-in

Caregiver Qualifications & Preferences

Desired caregiver gender:    Language preference:

Minimum experience (years):    CPR / First Aid required: Yes    Certification required (specify):

Background check required: Yes    Driver's license required: Yes

Authorizations, Consents, and Acknowledgments

By signing below, I authorize the agency and its authorized representatives to conduct caregiver candidate searches, to contact prior employers and personal references, and to perform background checks including criminal history, motor vehicle record checks where applicable, and verification of professional licenses or certifications as a condition of placement. I understand such checks are limited to information relevant to caregiver suitability and will be conducted in accordance with applicable law.

I authorize the release of medical and insurance information necessary to evaluate appropriate caregiver matches. This authorization includes release of relevant portions of medical records, care plans, medication lists, and functional status to prospective caregivers and to the agency facilitating the search, solely for the purpose of assessing care needs and caregiver qualifications.

This authorization is valid until: . I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization.

I acknowledge that the agency does not guarantee suitability beyond exercising reasonable care in screening candidates. I release the agency and its representatives from liability for acts or omissions of independently contracted caregivers, except in cases of gross negligence or willful misconduct by the agency in the screening process.

I understand the limits of confidentiality and privacy: information disclosed to prospective caregivers and references will be limited to what is necessary to evaluate fitness for the assignment. Personal health information will be handled in accordance with applicable privacy laws and retained only as necessary to fulfill the search and placement process.

I certify under penalty of perjury that the information provided in this form is true and complete to the best of my knowledge. I understand that false statements may affect eligibility for services and may have legal consequences.

I acknowledge that I have read and understand the privacy practices described above and authorize release of protected health information as set forth in this form.

Referral & Placement Instructions

Certification

I understand and agree that placement of a caregiver may be subject to terms and charges established by the agency or by the caregiver if engaged directly. Any financial arrangements, employment classification, insurance, or workers' compensation obligations must be addressed separately and in writing. The agency is not responsible for wages, benefits, or taxes unless explicitly agreed in a separate written placement agreement.

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