Health Information Management Team Onboarding Packet

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Pre-Employment Certification RegardingFederal Program Participation1. I understand that the term “Program” means any program funded wholly or partly by the federal or stategovernment, including Medicare, Medicaid, CHAMPUS and the Public <strong>Health</strong> Service.2. I certify that I am not and never have been excluded from or denied participation in a Program.3. I certify that I am not and never have been an owner or investor in any entity that has been excluded from ordenied participation in a Program.4. I certify that, to the best of my knowledge and belief, I am not under investigation for any charge that would resultin my exclusion from participation in a Program.5. I certify that, to the best of my knowledge and belief, I am not an owner or investor in any entity that is underinvestigation for a charge that would result in its or my exclusion from participation in a Program.6. I understand that if I am excluded from participation in a Program that my employer may not bill that Program forany services that I render and may not include the costs of my salary, wages or benefits on its cost reports.Therefore, I agree, as a condition of my employment, that I am financially responsible for any losses incurred bymy employer as a result of my employer’s inability to bill for services I perform if I am excluded from Programparticipation.7. I understand and agree, as a condition of my employment, that I am required to report to the VanguardCompliance Hotline (1-888-895-9945) any information I have that might indicate that I am under investigation fora charge that would result in my exclusion from participation in a Program.8. I understand and agree, as a condition of my employment, that I am required to report to the VanguardCompliance Hotline (1-888-895-9945) if I become excluded from participation in a Program.9. I understand and agree that my failure to inform my employer of information regarding actual or potentialProgram exclusion may result in immediate termination of my employment for cause.____________________________Signature____________________________Print Name___________________________Date___________________________Employee NumberDMC CompliancePre-Employment CertificationRevised 12/27/1126
______________________________________________ _________________________Last Name (Please print)First Name (Please print) ! " " ! ##RESPECTCOURTESY 1 2 3 +2 4 4 5 6 " 3 !7$%% " ! #$%% & #$%% & ! #♦ & ! #♦ & #♦ ! #♦ ' !! #♦ ( ) " #♦ & ) * + ,* " #$%% #♦ $ #♦ ! #♦ - . - & .#♦ " #+ #+ #♦ & -' / .♦ " 0 #27
Page 1 and 2: Welcome to theDetroit Medical Cente
Page 3 and 4: ON-SITE HIM DEPARTMENTHUMAN RESOURC
Page 5 and 6: SINAI-GRACE HOSPITALREPORTING FOR Y
Page 7: HUMAN RESOURCES NEW EMPLOYEE PAPERW
Page 14: IMPORTANT -- Requires Your Immediat
Page 18 and 19: Equal Employment DataThe DMC enters
Page 20 and 21: Veteran Status DefinitionsDisabled
Page 22 and 23: Acknowledgment and Acceptance of Em
Page 24 and 25: If You Think You Have BeenSubjected
Page 28 and 29: ___________________________________
Page 31 and 32: DMC PAYROLL SYSTEMIn an effort to b
Page 33 and 34: Employee Name:Electronic Direct Dep

Health Information Management Team Onboarding Packet

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