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(636) 220 1220

Home
About Us
Services
Join Our Team
Contact Us

(636) 220 1220

In-Home Services (IHS)

Personal Care Attendant Application

Please complete the application below to be considered for employment through the Consumer Directed Services Program. All applications are reviewed in accordance with program guidelines and background screening requirements.

Secure Home Healthcare Services LLC's consumers are equal opportunity employers and afford equal opportunity to all applicants without regard to race, religion, gender, national origin, age, disability, veteran status, marital or family status, genetic information or any other status protected under local, state or federal law. Per 19 CSR 15-8.400, Consumers are not allowed to employ spouses under the Consumer Directed Services program.PLEASE READ CAREFULLY BEFORE COMPLETING APPLICATION* Applicants will not be considered for employment by a consumer through the Consumer Directed Services program until Secure Home Healthcare Services LLC has completed all applicable background screenings including the Family Care Safety Registry (FCSR), Employee Disqualification List (EDL) and Office of Inspector General (OIG). If an applicant has certain offenses listed on the Family Care Safety Registry background check, the applicant will be notified if he/she is eligible to apply to the Missouri Department of Health and Senior Services (DHSS) for a “good cause waiver”. If applicable, the Missouri Department of Health and Senior Services may grant (approve) a “good cause waiver at their discretion. Applicants will not be eligible for employment by a consumer through the Consumer Directed Services program while a “good cause waiver” application is pending a decision.

* Applicants with disqualifying felonies cannot be employed by a consumer through the Consumer Directed Services program and will not be eligible to apply for a “good cause waiver” to work for a consumer through the Consumer Directed Services program with Secure Home Healthcare Services LLC as the vendor. Anyone listed on the Employee Disqualification List (EDL) will not, under any circumstances, be employed by a consumer through the Consumer Directed Services program and may not apply for a “good cause waiver” to work for a consumer through the Consumer Directed Services program with Secure Home Healthcare Services LLC as the vendor.

* If an individual is hired to work for a consumer under the Consumer Directed Services program, they will be screened against the Family Care Safety Registry (FCSR) at a minimum once a year. The Employee Disqualification List (EDL) will be checked four times a year and the Office of Inspector General’s List of Excluded Individuals and Entities will be checked monthly. If any inappropriate listings appear on either of these background checks, the individual will be notified and immediately become ineligible to receive payment through the Consumer Directed Services program. All individuals hired are registered with the Missouri Department of Social Services New Hire Reporting System.

My signature below indicates that I have thoroughly read and comprehended the information above:

Electronic Signature (Full Legal Name)

Date

Prefix

First Name

Middle Name

Last Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Country

Social Security Number

Date of Birth

Home Phone

Cell Phone

Work Phone

Driver's License State

Driver's License Number

Non-Driver License State

Non-Driver License Number

Are you 18 years of age or older?YesNo

Do you live in the city of Kansas City?YesNo

Are you Guardian, Conservator or Acting Power of Attorney for the person you are applying to work for?YesNo

If YES, please state which one:

Are you married to the person you are applying to work for?YesNo

Are you related to the person you will work for?YesNo

If YES, how are you related?

Have you lived in any other state in the past 5 years?YesNo

If YES, list the states

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Note: Attendant information may be subject to requests made pursuant to Missouri Revised Statutes Sections 610.010 to 610.200.

Your signature confirms that the answers given in this application are true and accurate to the best of your knowledge.

Electronic Signature (Full Legal Name)

Date

Consumer's Name

Personal Care Attendant Start Date

Rate of Pay $

USD

About Us

As expressed by local physicians, there is a strong need for quality In-Home Healthcare Services. The United States is expected to see an increase in the demand for home health and personal care as the population ages. Secure Home Healthcare Services is focused on making an impact in you and/or your loved one’s lives.

Services

Personal Care

Meal Prep/Planning

Mobility/Transfer

Alzheimers/Dementia care

Respite Care

Healthy Children/Youth Program

Advance Personal Care

Authorized Nurse Visits

Homemaker Services & Laudry

Companionship/Social And More

Contact us

134 Enchanted Parkway, Suite 203, Manchester, MO 63021
(636) 220 1220
1-800-924-4916
(636) 220-0020
info@securehomehealthcareservices.com
www.securehomehealthcareservices.com

Serving areas

St. Louis City and Country, St. Charles City and County, Wentzville, Lincoln, Pacific, St. Genevieve, Cape Girardeau, Jefferson, St. Clair, Warren, Washington, and surrounding areas.