Healthcare Travel Assignment Package

HEALTHCARE TRAVEL ASSIGNMENT PACKAGE

Assignment Summary

Facility Name:    Department/Unit:

Assignment Start Date:    Assignment End Date (if applicable):    Shift:

Expected Weekly Hours:    On-Call Requirement: Yes    No

Clinician Information

Professional Credentials & Health Compliance

Compensation, Travel & Housing

Hourly Rate: $    Overtime Rate (if applicable): $

Housing Provided: Yes    No    Housing Stipend Amount: $

Travel Reimbursement Method:    Per Diem: $

Expense Submission Deadline: days with receipts required: Yes    No

Assignment Terms & Conditions

Engagement Status: The parties agree that the Clinician will perform services as an independent contractor unless a separate employment agreement is executed. The Clinician is responsible for all applicable taxes, insurance, and licensure maintenance unless otherwise provided in writing.

Scope of Services: The Clinician shall perform professional duties consistent with the Clinician's licensure and training and as directed by the Facility. The Clinician will not perform services beyond the authorized scope of practice or assume supervisory responsibility unless expressly agreed in writing.

Credentialing & Clearance: Assignment is contingent upon satisfactory completion and verification of credentials, background check, drug screening, health clearances, and any facility-required orientation. Failure to provide accurate documentation or falsification of credentials constitutes grounds for immediate termination and may subject the Clinician to civil and criminal penalties.

Termination: Either party may terminate the assignment for cause or for convenience with written notice as set forth in this Agreement. The Facility may remove the Clinician for cause at any time. Compensation will be paid for hours worked through the date of termination in accordance with the pay schedule below.

Compliance, Confidentiality & HIPAA

Confidentiality: The Clinician shall keep confidential all patient information and facility business information and shall comply with all applicable privacy and security laws. The Clinician agrees to execute and abide by the Facility's confidentiality and security policies while on assignment.

HIPAA Acknowledgement: The Clinician acknowledges responsibility to comply with HIPAA privacy and security requirements and certifies training has been completed for the current assignment. Breach of protected health information obligations may result in termination and liability for damages.

Certifications, Authorizations & Representations

The Clinician certifies that all information provided in this package is true, complete, and accurate. The Clinician authorizes the Facility and/or staffing agency to verify credentials, employment history, references, criminal background, and health records as necessary. The Clinician consents to drug screening and to the release of records to the Facility/agency for credentialing and credential audits.

Authorization & Expiration

This Assignment Package and all authorizations contained herein remain effective until: unless earlier terminated in accordance with the terms set forth above.

By signing below, the Clinician and the Facility/Agency acknowledge and agree to the terms of this Healthcare Travel Assignment Package. The Clinician affirms that falsification of credentials or material misrepresentation is cause for termination and may be reported to licensing authorities.

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