Ginger Fitness and Rehabilitation, Inc
Ginger Fitness and Rehabilitation, Inc
                   We Are Special Because We Care
Exercises on
   

Consultations throughout the state
Call: 813-631-9700

Temple Terrace, Central-East Tampa, Brandon
5035 E. Busch Blvd., Ste 7 Tampa, FL 33617

Lakeland Plant City Clinic
1701 South Alexander Street, Suite 111, Plant City, FL 33566

Westchase,South Tampa, Carrollwood, Town&Country
8455 West Linebaugh Ave Tampa, FL 33625

New Tampa-Wesley Chapel Clinic
27553 Cashford Circle
Wesley Chapel,
FL 33544

Trinity/ New Port Richey
8726 Old County Road 54,
New Port Richey,
FL 34653

NEW PATIENT FORM Prescription Form Picture Gallery Jobs-Internships Volunteer - Students New Hire Paperwork DragonAPS Mobile Site

Ginger Health - PT/PTA New Employment Check List

  1. GFR Employment Agreement   Employment   Contractor/1099
  2. Application for Employment. (4 pages)
  3. Employee/Contractor Information/Emergency Sheet. (Do not leave bottom of form blank)
  4. Employment Eligibility Verification ** I9 link 9 pages Click here to Upload Form I-9
  5. Form W-4(for employee only) ** W4 link 2 pages Click here to Upload Form W-4
  6. Form W-9 (for Contractor/1099 only) ** W9 link Click here to Upload Form W-9
  7. Affidavit of Good Moral Character. Print (2 pages - must have notarized)
  8. Ginger Health Philosophy, practices and expectations
  9. Non-compete Clause and Confidentiality Agreement
  10. Ginger Health "PT/PTA" Code Of Ethics
  11. Statement of Health Form Print (1 page, Dr must sign)
  12. HIPAA Information.
  13. Agreement regarding use of cell phone while driving
  14. Automobile Insurance Agreement
  15. Ginger Health Policy and Procedure Manual [update in process]
  16. "APTA" Member # exp date:
    Other: Membership Affiliations / Certifications [enter] Name, Id #, Expiration date
    a. #
    b. #
    c. #

  17. FL Professional License exp
  18. National Provider Identifier [NPI] #
  19. Insurance Affiliations - Provider # [Enter] Your ID Number # below
    * CAQH # * Medicare # * FL Medicaid #
    * BCBS of FL# * CMS # * United Healthcare
    Other Insurance: Name / ID#
    1. #
    2. #
    3. #

  20. HIPAA Training – ** click link email Certificate of Completion
    a. Email a copy of Certificate to Office@GingerFitness.com
  21. Fraud and Abuse Training ** click link - Copy/Email Certificate Completion
    a. Email a copy of Certificate to Office@GingerFitness.com

BOLD: Employee must provide.

  1. Resume
  2. Copy of FL Professional License [enter] current expiration date.
  3. Copy of Driver License [enter] current expiration date.
    Dr. License number
  4. Copy of Social Security Card (for taxes / paycheck).
  5. Copy of CPR Card [enter] current expiration date
  6. Copy of Current Auto Insurance Card
  7. Copy of Degree or Diploma awarded
  8. Copy of Medical Errors Training
  9. Copy of HIV / Aids Training
  10. Copy of Background Screening – results within previous 6 months
  11. Copy *Contractor/1099-only* Professional Liability
    • Insurance Company
    • Coverage dates to
    • Limits $ per claim $ Aggregate
Administrator Use:
DragonAps [Login/PW] # Keys [Circle Location[s]: WC / LB / NT / ST] Alarm Code
OIG search FL New Hire Reporting [online]
 
Orientation Packet [Insurance Credentialing Instructions]
MCR 855R MCD Group Form Availity Login – BCBS application
CMS Optum/UHC Staywell
 
Office / Therapist Staff Employee

This agreement, made and entered into this day of , by and between Ginger Fitness & Rehabilitation, inc., a Florida Corporation, hereinafter referred to as (GFR), and , Office / Therapist Staff, hereinafter referred to as Employee.

This is an employee-employer relationship. Taxes are withheld as required by federal and state law. The rate is $ / hour, on an as needed, on-call basis, and flexible schedule. There is no guarantee of hours due to fluctuation of patient case load. There is no benefit of holiday / vacation, or health insurance. Other benefits may be given in the year, at the discretion of GFR.

(initial) I understand that I am in a trial period for 3 months, including pending my background and credentials check. I or GFR can decide to terminate any time.

Employee agrees to abide by all the requirements set forth, and understand that any breach of conduct or lack of cooperation with company philosophy and requirements may automatically terminate the relationship with GFR.

1. GFR's company philosophy: Getting to the Root of the Problem ©
  • Promoting proper health choices by first finding the "root" of the problem. To treat naturally and scientifically, to allow the body sufficient time to recover and improve. Each patient/client is encouraged to look at his/her health project as a long term habit. Just as one has to eat well to survive well, one also has to exercise correctly to improve his/her health and feeling of well-being. When the Ginger root is healthy, then the effects are manifested in the healthy plant and beautiful flower.
  • Employees are expected to lead by example, to make all attempts to live and practice good health habits, promote preventive health and proper rehabilitation, and grow personally and professionally, by continually updating knowledge and becoming active in their community and professional circles.
2. Professionalism - Employees are expected to demonstrate the following:
  • Practice good citizenship as demonstrated by good character, willingness to help others, etc.
  • Proactive at work: initiating steps to improve the work environment, seeking ways to improve relationship with fellow employees, seeking solutions to improve company operations, providing constructive ideas to improve self and company.
  • Pledge to exercised at least 2x/wk (list activities):
  • Good interpersonal skills, proper attire and professionalism during community and client visits (pants/skirt/dress length below knee, dress shorts, clean closed toe shoes, White or Dark Forest Green Polo, clothing do not reveal undergarments; tidy hair without hiding eyes, proper eye contact and clear directions given to patient during each session; good oral and other personal hygiene.)
  • Work quickly and efficiently, uses time in a constructive manner. Each employee is responsible to greet each patient with a smile and positive affirmations. Each employee is responsible with the maintenance and upkeep of each clinic, to include: (wiping down equipment after each treatment, cleaning restrooms, waiting area, laundry, office supplies) See clinic maintenance check list.
Employee Signature: Position Title Date:
Sharman Atkin, Administrator signature: Date:
EMPLOYMENT APPLICATION
APPLICANT INSTRUCTIONS

If you need help filling out this application form or for any phase of the employment process, please notify the person that gave you this form and every effort will be made to accommodate your needs in a reasonable amount of time.

1. Please read "APPLICANT NOTE" below.
2. Complete both sides of this page.
3. If more space is needed to complete any question. use comments section at the bottom of this page.
4. Print clearly; incomplete or illegible applications will not be processed. Please note "Not Applicable" if not answering a question.
5. Some packets may include an AFFIRMATIVE ACTION QUESTIONNAIRE. This information is being gathered for affirmative action under Section 503 of the Rehabilitation Act of 1973. The information requested is voluntary and will be kept confidential. An applicant will not be subject to any adverse treatment for refusing to complete the questionnaire.
6. DO NOT FILL OUT ANY OTHER ATTACHED FORMS OR PAGES UNTIL INSTRUCTED.
TODAY'S DATE:
NAME: LAST: FIRST: ML:
SOCIAL SECURITY NUMBER:
HOME PHONE: WORK PHONE:
CURRENT ADDRESS: STREET:
CITY: STATE: ZIP:
PRIOR ADDRESS: STREET:
CITY: STATE: ZIP:
APPLICANT NOT
This application form is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified applicants will receive consideration without discrimination because of sex, marital status, race, color, age, creed, national origin, sexual orientations, military reserve membership, ancestry, religion, height, weight, use of a guide or support animal because of blindness, deafness or physical handicap, or the presence of disabilities. A felony conviction will not necessarily bar an applicant from employment. Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment. After an offer of employment, and prior to reporting to work, you may be required to submit to a medical review. Depending on company policy and the needs of the job, you will be required to complete a medical history form and may be required to be examined by a medical professional designated by the company.
AVAILABILITY
For which position are you applying?
What date can you start?
What category would you prefer? Full-time     Part-time/Temporary    Labor pool
For which schedules are you available?* Weekdays    Weekends     Evenings     Nights     Overtime     Shift     Other
JOB-RELATED SKILLS
NOTE:Do not fill out any part of this section you believe to be non-job related.

Yes       No If the job requires, do you have the appropriate valid drivers license?
Name on license DL# State of issue
Yes       No Have you had any moving violations? Please describe.
Please list any other skills, licenses or certificates that may be job-related or that you feel would be of value to this job or company:
Yes       No Have you been given a job description or had the essential functions of the job explained to you?
Yes       No Do you understand these essential functions?
Yes       No Can you perform the essential functions of this job with or without reasonable accommodation? List languages in which you are fluent
SECURITY
List states and counties of residence for the past seven ears

Yes       No Have you used any names or Social Security Numbers other than given above? If so, please list in comments, below.
Yes       No Have you been convicted of a crime in the past seven years? If so, please describe in the boxes below. (Conviction will not necessarily be a bar to employment. (In accordance with company policy and applicable state and federal laws, factors such as age at time of the offense, remoteness of the offense, time since last conviction, nature of the job sought and rehabilitation effort will be reviewed.)
INCIDENT CITY/STATE CHARGE
1.
2.
COMMENTS
ASK FOR ADDITIONAL PAGE IF NECESSARY
PREVIOUS EMPLOYERS
PLEASE NOTE. Your application will not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical: Ask for a phone book or call information If necessary. FOR EMPLOYERS OUTSIDE THE U.S., A CURRENT FAX NUMBER IS MANDATORY.
MOST RECENT EMPLOYER Yes           No Are you currently working for this employer? PHONE
Yes         No If yes, may we contact? FAX


COMPANY NAME

CITY

STATE
FROM TO
DATE EMPLOYED
JOB TITLE
SUPERVISOR NAME

DUTIES
PER
SALARY                       (HOUR, WEEK, MONTH)
REASONS FOR LEAVING
SECOND MOST RECENT EMPLOYER   PHONE
  FAX


COMPANY NAME

CITY

STATE
FROM TO
DATE EMPLOYED
JOB TITLE
SUPERVISOR NAME

DUTIES
PER
SALARY                       (HOUR, WEEK, MONTH)
REASONS FOR LEAVING
THIRD MOST RECENT EMPLOYER   PHONE
  FAX


COMPANY NAME

CITY

STATE
FROM TO
DATE EMPLOYED
JOB TITLE
SUPERVISOR NAME

DUTIES
PER
SALARY                       (HOUR, WEEK, MONTH)
REASONS FOR LEAVING
REFERENCE
Include only individuals familiar with you work ability. Do not include relatives.

Name Address/Phone Years Known/Relationship
1.
2.
EDUCATION
NOTE: Do not fill out any part of this section you believe to be non job-related.
Please circle the highest grade completed. 7      8      9      10      11      12      13      14      15      16      16+
If your school records are under a different name than listed on page 1, please enter that name:
  Name Yrs. Attended City/State Yr. Graduated Degree Type
HIGH SCHOOL  
COLLEGE
TECHNICAL SCHOOL
OTHER
CERTIFICATION AND RELEASE
 I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information. omissions or misrepresentations of facts called for in this application, whether on this document or. not, may result in rejections of my application or discharge at any time during my employment. I authorize the company and/or its agents. including consumer reporting bureaus, to verify any of this information. I authorize all former employers, persons, schools, companies and law enforcement authorities to release any information concerning my background and heteby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
SIGNATURE
DATE
Addendum

Employee input: hand-write 2-3 paragraphs about why you are a Therapis/Therapist Assistant/Clinic/office staff and what projects do you want to see happening in the PT professional community and in the general community where you live.
Employee/Contractor Information/Emergency Sheet
(Will be kept confidential and used for emergency purposes only)
Employment/Contractor Start date: End date:
Name:
DOB: SSN: Gender: Male      Female
Address:
Email Address:
Home #: Cell #: Other #:
Contact in case of Emergency
Name 1: Relationship:
Address:
Phone: Alternate Phone:
Name 2: Relationship:
Address:
Phone: Alternate Phone:
Medical Information
HospitaI Preference
Medical Doctor's Name:
 Phone
Specialists (list):
Allergic Reactions:
Medications:
Health Issues/Precautions:
SIGNATURE
DATE
Exercise Equipment _ Orientation Use and Safety
** DO NOT allow children or adults who are not patients to use any exercise machines **
** DO NOT allow them to play on any PT equipment, including weights and therapy balls **
  • TREADMILL - Begin with Power off / lowest incline to 0
    • Place safety belt (martial arts belt) on patient around waist firmly
    • Wrap emergency band firmly around wrist or waist
    • In Emergency pull out this band
    • DO NOT allow children or adults who are not patients to use any exercise machines. Hide the emergency band where they can't get to, so they cannot activate treadmill.
    • Start treadmill on lowest speed 0.5
    • Increase speed and increase incline [per Physical Therapist direction]
    • Stand holding on to patient by safety belt firmly [depends on patient. PT will give directions]
    • Decrease speed and decrease incline for cool down
    • Stop treadmill
    • Assist patient off the treadmill if needed
    • Patients can walk sideways, backwards, according to rehab needs with supervision.
  • BIOSTEP: - Begin with Power off
    • Turn and Pivot the seat by lever so patient can sit on seat
    • Turn the seat facing the pedals
    • Adjust seat forward or backward (knees should be slightly flexed, not hyperextended. Feet should be as flat on pedals as possible)
    • Set the Weight, time and/or program level {level determine by PT}
    • When patient starts to pedal, the machine will calculate time, steps and intensity for duration
    • When patient is done, assist out of chair. Turn left or right to pivot the chair.
    • Assist patient off the biostep if needed.
  • Stepper: - Start and Reset if already programmed
  • Abcoaster:
    • Be sure pt is using it slowly with control, not quickly up/down.
    • Pt must pull platform all the way past the marker point for counter to count and move through full ROM.
    • Pt must SLOWLY lower legs for good controlled eccentric contracts and prevent injury to low back
  • HIVAMAT:
    • Always recharge machine after you are done
    • Always wear gloves on both hands, so you don't inadvertently shock pt.
    • (Time Intervals , , )
  • Ultrasound Machine:
    • Caution: do not allow head of US to be removed from touching skin surface while machine is running, this will destroy the US head crystals.
  • TENS/ Iontophoresis:
    • Caution: do not pull or allow for electrodes to be pulled inadvertently during treatment or pt will be shocked.
    • Staff will be given specific instructions at time of treatment.
    • Check skin condition prior and after treatment to be sure there is no irritation.
Employee Name Print

Employee Signature Date

Ginger Fitness & Rehabilitation, Inc.
Employees, Contractors, Students, Volunteers
Non-complete Clause and Confidentiality Agreement

I, , agree to become Employee/Contractor/Volunteer/Students of Ginger Fitness and Rehabilitation, Inc. (GFR) with the following conditions:

Definition: Customers of GFR mean rehabilitative patients, wellness or fitness clients, contracting agencies, and or individual and corporate clients on a consultation basis. Customers can mean corporation entries, agencies, or individuals, or private or community groups.

During the time that I treat or see customers of GFR, I will not try to solicit business for another company.

After I have terminated my relationship with GFR, during a period of 2 years, I will not have business relations with customers of GFR without approval by GFR.

Confident Information includes not only information labeled as such, but also includes, and is not limited to all patient and family information, business information, patient referrals lists, financial and marketing information, patient charts and information, business plans, treatment programs, proprietary materials, and all other information confidental to Ginger Fitness and Rehabilitation, Inc. (GFR).

I understand that during the course of my employment/contracting with GFR, I will receive and have access to confidental information and that such confidental information is owned by GRF. I also understand that the release of such information to third parties would cause damage to GFR. As a result, I agree not to disclose any GFR confidential information which I receive to any third party, except as may be provided by or required by law.

I will also keep all records and information of GFR's contracts confidential, as directed by GFR and those agencies/companies' guideline for contracting.

I will keep all records of my dealings with GFR confidential to myself, without sharing among my family, employees, or third party without prior written authorization from GFR

I will delete from my personal files all patient information, including any paper and electronic copies or communications unless required by law or with GRF's written approval.

This agreement will survive termination of my employment/contracting/volunteer/student clinical with GFR.

Printed Name:
Signature: Date:

Ginger Fitness & Rehabilitation, Inc

HIPAA Confidentiality Agreement

All information relating to patients must be sent only to relevant persons in care of the patient or coordinating patient care. Ask before sending out any types of communication if you have any questions.

Notice of Privacy Practice
See enclosed forms. Use for all new patients. Patients have the right to restrict their privacy information as appropriate for them. All information sent about patients outside of direct patient care or coordination must have patient approval. Contact GFR if you have any questions.

Use of faxes, email, or any other electronic means
Use the statement below or similar for your electronic transmission face sheet or communications: The information transmitted is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. Any review, retransmission, dissemination or other use of, or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this in error, please contact the sender and destroy the material and/or delete the material from any computer.

HIPAA Training Acknowledgement

I have received instructions about HIPAA as relevant to my employment/contracting with Ginger Fitness and Rehabilitation, Inc. (GFR)

As a staff member/contractor for GFR, I recognize that candid and objective discussions of patient conditions are necessary for effective care and management. I further acknowledge the right of each patient to not have personally identifiable medical and / or individual patient. I agree to respect and maintain the confidentiality of all discussions, deliberations, information and records whether in written, electronic, and/or other formats, generated in connection with the care of patients.

I understand that by signing this agreement I am biding myself by contract to maintain such confidentiality. I agree that I will not make any voluntary disclosure of such confidental information except to persons authorized to receive it. This obligation of strictest confidence shall survive the termination of my employment or contact.

Printed Name:
Signed: Dated
Position of Title:

Ginger Fitness & Rehabilitation Physical Therapy For 0-100+
Agreement Regarding Use of Cell Phone while Driving

Using cell phones while driving is distracting and dangerous, including talking, dialing, text messaging, use of the internet, emails, etc. Ginger Fitness and Rehabilitation, Inc. does not require that employees use cell phones for any business and patient care purposes while driving.

Employees are responsible for his/her own action while using cell phones.

I , understand that I am informed of Ginger Fitness & Rehabilitation, Inc.'s policy on cell phone use while driving. I understand that I am under no obligation to use the cell phone while driving.

Signed: Date:

Ginger Fitness & Rehabilitation, Inc

Automobile Insurance Agreement

I hereby agree that I will carry automobile liability insurance as provided by current Florida Statutes.

I hereby agree to indemnify and hold harmless Ginger Fitness and Rehabilitation, Inc. from any claims arising out of the negligence of my motor vehicle

I further agree to inform Ginger Fitness and Rehabilitation, Inc immediately of any incident, accident which may occur while on business, cancellation of insurance policy and other pertinent facts pertaining to my automobile insurance

Upon request, I can provide a copy of my insurance face/declaration page showing effective dates and liability limits.

Employee name:
Employee signature:    Date:

Ginger Fitness & Rehabilitation, Inc
27553 Cashford Circle, Suite 101
Wesley Chapel, Florida 33544
813-631-9700 fax: 813-631-9770

I have received or read a copy of the GFR Policy and Procedure Manual, specifying policies, practices, and regulations, which I agree to observe and follow during my employment with the company. I understand that it is my responsibility to be familiar with its contents and to ask questions on any matters I don't understand.

Employee Signature Date

Ginger Fitness & Rehabilitation
New Employee Checklist

For:
Date of hire:

Welcome to Ginger Fitness & Rehabilitation
Physical Therapy For 0-100+

Introduce employee to co-workers, and review policy handbook
Orient employee to clinic, and give tour:
  • Bathrooms
  • Photocopy machine
  • Fax machine
  • Supplies
  • Linen closets
  • All Modalities (ho+, ice packs, US machine, TENS Unit)
  • Cleaning list and supply location
Review clinic policies and procedures:
  • Timesheets
  • Dress Code
  • Hygiene
  • Hours of Work
  • Work Rules
  • Attendance Policy
  • Phone etiquette
Review safety procedures:
  • Proper use of gait belt
  • Lifting techniques
  • Location of first aid and emergency supplies
  • BP Cuff
Introduce Elite scheduling and program
  • Summergate Clinic
  • Westwood Clinic
  • Temple Terrace Clinic
  • Harc
  • Pyramid
  • McDonald Training Center
Thank you for visiting Ginger, Have a Harmonious and Healthy Year!
813-631-9700
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