APPLICATION FOR EMPLOYMENT

General Information Name (Last, First, Middle)

SSAN

Current Address

City State Zip

Phone

Referred By

Position Desired Date Available Salary Desired

Currently Employed? Yes No May we contact current employer? Yes No Have you ever applied/worked with this company before? Yes No When?

Education Name/Location of School Year Completed Graduate? Subject/Degree

High School College(s)

Trade/Business School(s)

Employment (Start with most recent)

Date (Month/Year) Name/Address of Employer Salary Position Reason for Leaving From To

From To

From To

From To

From To

From To

References (Three persons not related to you, preferable from an employment setting)

Name Address Phone In what capacity have you known this person?

Authorization I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that any falsified statements on this application may be grounds for dismissal. I authorize investigation of all statements herein, to include contacting references and prior employers/schools that may have pertinent information, personal or otherwise. I release any school, former employer or reference from any and all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. Signature Date

Accutrack Services, LLC Employee Data Form

Employee Name: Effective Date:

Type of Action

New Hire Data Change Termination

Complete Each Applicable Section

Address:

Status: Full Time Part Time Per Diem Estimated Hours Per Week:

Position: Primary Work Site:

FLSA Status: Exempt Non-Exempt Eligible for Rehire: Yes No

Pay Rate: Salary____________ Hourly_____________ Other

Other:

Approval Signature: Date:

Notes:

File Completed Form in Employee File

Employer Information

1. Federal Employer ID Number (FEIN): 2. State Employer ID Number (Optional): Please use the same FEIN that appears on quarterly wage reports.

3. Employer Name:

4. Employer Address (Please indicate the address where the Income Withholding Orders should be sent):

5. Employer City (if US): 6. State (if US): 7. ZIP Code (if US):

_ 8. Province/Region (if foreign): 9. Country (if foreign): 10. Postal Code (if foreign):

11. Employer Telephone (Optional): 12. Employer FAX (Optional):

13. New Hire Contact Person (Optional):

Employee Information

14. Social Security Number (SSN): 15. First Day of Work (MM/DD/YYYY) (Optional):

16. Employee First Name:

17. Employee Middle Name:

18. Employee Last Name:

19. Employee Home Address:

20. Employee City (if US): 21. State (if US): 22. ZIP Code (if US):

_ 23. Province/Region (if foreign): 24. Country (if foreign): 25. Postal Code (if foreign):

26. State Where Employee Was Hired (Optional): 27. Employee DOB (MM/DD/YYYY) (Optional):

28. Employee’s Salary (Dollars and Cents) (Optional):

29. Salary Frequency (Check One ONLY) (Optional):

Hourly Weekly Biweekly Semi-Monthly Monthly Annually

Texas Employer New Hire Reporting Form Submit within 20 calendar days of new employee’s

first day of work to:

ENHR Operations Center, P.O. Box 149224 Austin, TX 78714-9224

Phone: 1-800-850-6442 FAX: 1-800-732-5015 Online: http://employer.oag.state.tx.us

To ensure the highest level of accuracy, please print neatly in capital letters and avoid contact with the edges of the boxes. The following will serve as an example:

A B C 1 2 3

REV 8/07 ENHR RPT FORM

INSTRUCTIONS FOR COMPLETING THE TEXAS EMPLOYER NEW HIRE REPORTING FORM The purpose of the Texas New Hire Reporting Form is to allow employers to fulfill new hire reporting requirements. You may enter your

employer information and photocopy a supply and then enter employee information on the copies.

REPORTING OF NEW HIRES IS REQUIRED: All required items (numbers 1, 3, 4, 5, 6, 7, 14, 16, 17, 18, 19, 20, 21, 22) on this form must be completed.

Box 1: Federal Employer ID Number (FEIN). Provide the 9-digit employer identification number that the federal government assigns to the employer. This is the same number used for federal tax reporting. Please use the same FEIN that appears on quarterly wage reports.

Box 2: State Employer ID Number (Optional). Identification number assigned to the employer by the Texas Workforce Commission.

Box 3: Employer Name. The employer name as listed on the employee’s W4 form. Please do not provide more than one employer name (for example, “ABC, Inc DBA. John Doe Paint and Body Shop” is not correct).

Box 4: Employer Address. Please indicate the address where the Income Withholding Orders should be sent. Do not provide more than one address (for example, P.O. Box 123, 1313 Mockingbird Lane is not correct).

Box 8: Employer Province/Region (if foreign). Provide this information if the employer address is not in the United States.

Box 9: Employer Country (if foreign). Provide the two letter country abbreviation if the employer address is not in the United States.

Box 10: Postal Code (if foreign). Provide the postal code if the employer address is not in the United States.

Box 13: New Hire Contact Person (Optional). Providing the name of a contact staff person will facilitate communication between the employer and the Texas Employer New Hire Reporting Program.

Box 15: First Day of Work (Optional). List the date in month, day and year order. Use four digits for the year (for example, 2001). This should be the first day that services are performed for wages by an individual. If you are reporting a rehire (where a new W-4 is prepared) use the return date, not the original date of hire.

Box 23: Employee Province/Region (if foreign). Provide this information if the employee does not reside in the United States.

Box 24: Employee Country (if foreign). Provide the two letter country abbreviation if the employee address is not in the United States.

Box 25: Postal Code (if foreign). Provide the postal code if the employee address is not in the United States.

Box 26: State Where Employee was Hired. Use the abbreviation recognized by the U.S. Postal Service for the state in which the employee was hired.

Box 27: Employee DOB (Date of Birth) (Optional). List the date in month, day and year order. Use four digits for the year (for example, 1985).

Box 28: Employee Salary (Optional). Enter employee’s exact wages in dollars and cents. This should correspond to the salary pay frequency indicated in Box 29.

Box 29: Salary (Check One ONLY) (Optional). Check the appropriate box relating to the employee’s salary pay frequency. Check “ Bi-weekly” if the salary is based on 26 pay periods. Check “Semi-monthly” if the salary is based on 24 pay periods. Check “Annually” if salary payment is a one-time distribution.

SUBMISSION OF NEW HIRE REPORTS. The Texas Employer New Hire Reporting Program offers a variety of methods that employers can use to submit new hire reports. For further information on which method may be best for you, call 1-800-850-6442. Employers are encouraged to keep photocopies or electronic records of all reports submitted. When the form is completed, send it to the Texas Employer New Hire Reporting Program using one of the following means:

• FAX: 1-800-732-5015 • U.S. Mail:

ENHR Operations Center P.O. Box 149224

Austin, TX 78714-9224

• Telephone Submissions: 1-800-850-6442 • Internet Submissions: http://employer.oag.state.tx.us

Employers must provide all of the required information within 20 calendar days of the employee's first day of work to be in compliance. State law provides a penalty of $25 for each employee an employer knowingly fails to report, and a penalty of $500 for conspiring with an employee to 1) fail to file a report or 2) submit a false or incomplete report. REV 08/07 ENHR RPT FORM

Training Acknowledgement

I acknowledge that I have received training concerning Protected Health Information, including state and federal legal requirements and practice policy.

____________________________________________

Employee Name

____________________________________________

Signature

____________________________________________

Date Training Received

Page | 1

Accutrack Services, LLC Employee Acknowledgements

_____________________________________ __________ Employee Printed Name Date 1. Policy and Procedure Acknowledgement

My signature on this document acknowledges the fact that I have been provided access to the policies and procedures of Accutrack Services, LLC and have had the opportunity to review them and ask any questions that I may have concerning the policies.

I further understand that policies and procedures may change from time to time and that it is my responsibility to review pertinent policies and procedures as necessary in order to remain current. Accutrack Services, LLC will announce substantive changes to policies when they occur.

Policies are available on the office network for review at any time. A hard copy of the policy and procedure manual is maintained at the business office and can be made available on request

____________________________________ Signature

2. WORKFORCE CONFIDENTIALITY AGREEMENT I understand that Accutrack Services, LLC has a legal and ethical responsibility to maintain patient privacy, including obligations to protect the confidentiality of Patient Information and to safeguard the privacy of Patient Information. In addition, I understand that during the course of my employment/assignment/affiliation with Accutrack Services, LLC, I may see or hear other Confidential Information such as financial data and operational information pertaining to the practice that Accutrack Services, LLC is obligated to maintain as confidential. As a condition of my employment/assignment/affiliation Accutrack Services, LLC I understand that I must sign and comply with this agreement. By signing this document I understand and agree that: I will disclose Patient Information and/or Confidential Information only if such disclosure complies with Accutrack Services, LLC policies, and is required for the performance of my job. My personal access codes(s), user ID(s), access key(s) and password(s) used to access computer systems or other equipment are to be kept confidential at all times. I will not access or view any information other than what is required to do my job. If I have any questions about whether access to certain information is required for me to do my job, I will immediately ask my supervisor for clarification.

Page | 2

I will not discuss any information pertaining to the practice in an area where unauthorized individuals may hear such information (for example, in the hallways, on elevators, in restaurants, etc.). I understand that it is not acceptable to discuss any Practice Information in public areas even if specifics such as a patient’s name are not used. I will not make inquiries about any Practice Information for any individual or party who does not have proper authorization to access such information. I will not make any unauthorized transmissions, copies, disclosures, inquiries, modifications, or purging of Patient Information or Confidential Information. Such unauthorized transmissions include, but are not limited to removing and/or transferring Patient Information or Confidential Information from Accutrack Services, LLC’s computer system to unauthorized locations (for instance, home). Upon termination of my employment/assignment/affiliation with Accutrack Services, LLC, I will immediately return all property (i.e. keys, documents, ID badges, etc.) to Accutrack Services, LLC. I agree that my obligations under this agreement regarding Patient Information will continue after the termination of my employment/assignment/affiliation with Accutrack Services, LLC. I understand that violation of this Agreement may result in disciplinary action, up to and including termination of my employment/assignment/affiliation with Accutrack Services, LLC and/or suspension, restriction or loss of privileges, in accordance with Accutrack Services, LLC policies, as well as potential personal civil and criminal legal penalties. I understand that any Confidential Information or Patient Information that I access or view at Accutrack Services, LLC does not belong to me. I have read the above Agreement and agree to comply with all of its terms as a condition of continuing employment. ____________________________________ Signature

3. Workers Compensation Insurance Acknowledgement The State of Texas requires that employees receive a Notice to Employees Concerning Workers’ Compensation in Texas. This notification has been posted in the workplace and is also provided to you as an attachment to this acknowledgement. As Accutrack Services, LLC is covered by a commercial insurance policy, we are also required to provide the following statement: You may elect to retain your common law right of action if, no later than five days after you begin employment or within five days after receiving written notice from the employer that the employer has obtained workers’ compensation insurance coverage, you notify your employer in writing that you wish to retain your common law right to recover damages for personal injury. If you elect to retain your common law right of action, you cannot obtain workers’ compensation income or medical benefits if you are injured. ____________________________________ Signature

4. Marketplace Coverage Options and Your Health Coverage I acknowledge that I have received notice of Marketplace Coverage Options and Your Health Coverage. ____________________________________ Signature

El Paso Integrated Physicians Group, P.A. Compliance Pledge

As an employee or contractor of El Paso Integrated Physicians Group, P.A. (EPIPG,) I understand that I am expected to adhere to the standards of documentation, medical coding, and conduct described in the Compliance Program and other policies of EPIPG. I understand that it is my duty to observe and adhere to federal, state, and local laws concerning activities of EPIPG in general and my role in particular. I understand that failure to comply with this pledge will result in serious consequences including disciplinary action, possible termination of employment, monetary fines, and prosecution by the proper authorities when intentional violations are reported and substantiated. I also understand that I must advise EPIPG’s compliance officer, when I have knowledge of any violations of the Corporate Compliance Program and/or laws/regulations related to EPIPG’s activities. In the event the Compliance Officer is not available, I will notify the President of EPIPG. No one is subjected to reprisal, discipline, or discrimination based upon having made a report in accordance with this Pledge.

I have read this pledge and reviewed the Corporate Compliance Program carefully, have received training by the Compliance Officer or designee, and have no further questions concerning its intent or my responsibilities.

_________________________________________ Employee signature _________________________________________ Employee Printed Name _________________________________________ Date

Training Acknowledgement

I acknowledge that I have received training concerning Protected Health Information, including state and federal legal requirements and practice policy.

____________________________________________

Employee Name

____________________________________________

Signature

____________________________________________

Date Training Received

New Health Insurance Marketplace Coverage Options and Your Health Coverage

PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health

Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic

information about the new Marketplace.

What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The

Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible

for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance

coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or

offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on

your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible

for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be

eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does

not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your

employer that would cover you (and not any other members of your family) is more than 9.5% of your household

income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the

Affordable Care Act, you may be eligible for a tax credit.1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your

employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer

contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for

Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-

tax basis.

How Can I Get More Information? The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the

Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health

insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered

by the plan is no less than 60 percent of such costs.

Form Approved OMB No. 1210-0149 (expires 11-30-2013)

El Paso Integrated Physicians Group, P.A. 74-2838972 PO Box 3157 (915) 577-0051 El Paso TX 79923-3157 Bill Collins

PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an

application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered

to correspond to the Marketplace application.

3. Employer name 4. Employer Identification Number (EIN)

5. Employer address 6. Employer phone number

7. City 8. State 9. ZIP code

10. Who can we contact at this job?

11. Phone number (if different from above) 12. Email address BCollins@epipg.com

You are not eligible for health insurance coverage through this employer. You and your family may be able to obtain

health coverage through the Marketplace, with a new kind of tax credit that lowers your monthly premiums and with

assistance for out-of-pocket costs.

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