Application for Employment

Applicant’s Statement

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be helpful in arriving at an employment decision.

This application for employment shall be considered active for a time not to exceed 60 days. Any applicant wishing to be considered for employment beyond this time should later inquire as to whether or not applications are then being accepted.

I hereby understand and acknowledge that should I be employed by this or a related organization, any employment relationship will be of an “at will” nature, which means that I, the Employee, may resign at any time and the Employer may discharge me at any time with or without cause. It is further understood that there will be no contract of employment of any kind, regardless of any written or verbal statement(s) or other conduct, except and unless such obligation(s) is(are) explicitly set out in a written contract, labeled as a “contract” or “agreement”, and signed by both myself and the President of the Employer.

I also agree that in the event I am employed by this or a related organization, should I be advanced pay, vacation time, other compensation or benefits beyond what I am entitled to, if I have expense or other money beyond what I reasonably spent on behalf of Employer, if I have not returned Employer property (or other property entrusted to me), or if I am otherwise indebted to Employer, this money may be deducted from any final paycheck I receive upon conclusion of my employment; or, during my continued employment and in the case of debts other than vacation advances, limited payroll deductions of up to twenty percent of the net pay in successive paychecks may be made following my failure to otherwise repay Employer within forty-five days of written notice to me of this debt.

In the event of employment, I understand that false or misleading information given in my application process or interview(s) may result in my discharge at any time. If employed, I intend to maintain a productive and proper work effort.

AUTHORIZATION FOR RELEASE OF INFORMATION AND RECORDS
TO RETINA-VITREOUS CONSULTANTS, INC.

I, (name entered below), hereby authorize any person, organization, or business which has knowledge, experience, consumer/credit reports or other records concerning me to release such information to Retina-Vitreous Consultants, Inc. (attn. Administrator), 300 Oxford Drive, Suite 300, Monroeville, PA 15146-2357. I release such person, organization or business from any liability connected to providing this information. I further direct and authorize that each such person, organization or business provide a full, forthright, and frank disclosure to Retina-Vitreous Consultants, Inc., whether that disclosure is favorable or not.

This authorization, release, and direction includes, but is not limited to, any prior employer, neighbor, business associate, reference, criminal record custodian, consumer/credit reporting agency, college, university, school, institute, or other training program having knowledge or information regarding me. This authorization also includes release by Retina-Vitreous Consultants, Inc. of identifying information regarding me such as but not limited to my address and past employers or educational institutions I attended.

A copy of this Authorization is as valid and effective as the original. I acknowledge receipt of the "Summary of Your Rights Under the Fair Credit Reporting Act" (below).

I fully and knowingly make this authorization, release and direction by my signature below.

CONFIDENTIALITY AGREEMENT

As a visitor to Retina-Vitreous Consultants, Inc. (the “Practice”), you may come into contact with the protected health information (PHI) of our patients. For example, the fact that an individual is or was a patient of the Practice is PHI. Federal and State laws, including HIPAA, and our policies and procedures, protect the privacy and security of this PHI.

It is illegal for you to use or disclose PHI outside the scope of your visit to the Practice. This includes oral, written or electronic uses and disclosures.

Restrictions on the use of PHI

• You may not access, use, or take possession of PHI for any purpose unless specifically authorized to do so by the patient whose PHI is being used.
• You may NOT photocopy or scan any PHI.
• You may NOT photograph or record, on videotape or any other media, patients unless specifically authorized to do so by the patients.
• You will only be granted access to the minimum amount of PHI necessary to conduct the purpose of your visit.

I have read and understand the above information. I realize there are civil and criminal penalties for the unauthorized use and disclosure of PHI. I will abide by these restrictions while on-site at the Practice.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

• a person has taken adverse action against you because of information in your credit report;
• you are the victim of identity theft and place a fraud alert in your file;
• your file contains inaccurate information as a result of fraud;
• you are on public assistance;
• you are unemployed but expect to apply for employment within 60 days.

In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.ftc.gov/credit for additional information.

You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.ftc.gov/credit for an explanation of dispute procedures.

Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need — usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.ftc.gov/credit.

You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).

You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

Identity theft victims and active duty military personnel have additional rights. For more information, visit www.ftc.gov/credit.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. Federal enforcers are: