Employee Information

This form is a professional document and must be complete, true, and accurate. This information may, upon request, be furnished to those facilities which receive services from an employee nurse. Please fill in all the blanks.

Please be truthful and complete with the following information.

Please download, complete, and submit the Direct Deposit form located on NursesDirectLLC.com. All payments by Nurses Direct to employee will be made via direct deposit.

In accordance with the privacy regulations promulgated under the Health Insurance Portability and Accountability Act, 45 CFR parts 160 and 164. Nurses Direct and Nurse Employee understand and agree to abide by the facility privacy policies and to not use or further disclose a patient's personal health information except as expressly permitted by the agreement or as otherwise authorized in writing by the patient through a consent or authorization meeting the requirements of the privacy regulations. Nurses Direct LLC and Nurse Employee may only use a patient's personal health information for the sole purpose of treatment, and/or health care operations and may not release any information to unauthorized parties. Nurses Direct LLC and Nurse Employee agree to implement appropriate safeguards to prevent the unauthorized use and disclosure of any patient's personal health information received by facility under this agreement. In addition, Nurses Direct and Nurse Employee shall make available to the facility the protected health information for amendment purposes, should changes to the information be necessary or to provide an accounting of disclosures of the protection health information. If any unauthorized disclosure of personal health information occurs, Nurses Direct LLC and Nurse Employee shall immediately contact facility to inform them of the disclosure and any remedial action taken to prevent further disclosures Nurses Direct LLC and Nurse Employee understand that any unauthorized disclosure of a patient's personal health information is grounds for immediate termination of the agreement and/or staffing assignment.

I understand that due to my occupational exposure to blood and other potential infectious materials I may be at risk of acquiring an infectious disease. I have been given the opportunity to be vaccinated by the physician of my choice or facility of my choice at my own expense. If I have already received all required vaccines, I agree to provide documentation to verify to Nurses Direct.I understand that declining vaccines, I continue to be at risk of acquiring a serious disease. If in the future I continue to have occupational exposure to blood or potentially infectious materials and I want to be vaccinated, I can receive the vaccines from a physician and/or facility of my choice at my own expense.Below I hereby indicate that I decline the following vaccines or will provide documentation for any vaccines I have received in the past.