Affirmation Release Information:

Health Care Provider Status. By submitting this application, I hereby certify:

(a) that I am not currently nor ever have been (i) convicted of health care fraud (ii) convicted of a health care related crime (iii) suspended, sanctioned, restricted, or excluded from any government program, including exclusion from participating in any private, federal or state health insurance program (iv) convicted of making a false statement relating to a health care entity (vi) convicted of laundering money that came from the commission of a federal health care offense; and

(b) that I currently have no, nor ever had, direct or indirect ownership or controlling interest of 5% or more of a "sanctioned entity" that has been convicted of any offense under 42 CFR 1001.101 through 1001.104 or that had been, or is, terminated or excluded from any government program, including participation in Medicare or a Medicaid program, nor have I been an officer or managing employee of such an entity.

I understand that any offer to hire is subject to or contingent upon:
- Satisfactory completion of  post offer pre-employment physical examination
- Satisfactory completion of  post offer pre-employment drug test and nicotine test
- Receipt of adequate references
- Accuracy of pre-employment information furnished
- Compliance with Immigration Reform Control Act of 1986
- Other legitimate criteria as established by the TriHealth
- Satisfactory results of post-offer background screening, as applicable
-No restrictive covenants or non-competes
-Post-offer background screening as applicable

I understand that the shift, days, nature and facility location of my employment is subject to change, based upon the needs of the department, the Hospital, and/or TriHealth.

I understand and agree that if employed by TriHealth such employment may be terminated at will, i.e., the Hospital and I have the right to terminate the employment relationship at any time for any reason. I also understand that no employee, manager, or representative of the Hospital can orally modify or make promises altering the at-will nature of my employment. Furthermore, any employment agreement will be reduced to a formal, written document signed by me and a senior officer of the Hospital or the Senior Human Resources officer.

I, the undersigned, hereby authorize my former employers and others to furnish their records of my service, my reason for leaving their employment, together with all information they have concerning me (with the exception of salary information). I also release any individual, partnership, or corporation which formerly employed me, its officers, agents, and employees, from any liability for any damage whatsoever for issuing such information. Additionally, I hereby authorize any schools, colleges, or institutions of education I have attended to furnish their records and/or transcripts of my grades, honors, achievements that they may have concerning me. I also release any individual, school or institution, its officers, agents, and employees from any liability for any damage whatsoever for issuing such information. 

Clicking the 'Next' button below authorizes the release of reference information and affirms all the facts set forth in my application for employment as true and complete. I understand that if employed, false statements, omissions, or other misrepresentation by me on this application may result in immediate dismissal. I agree to sign/submit this application electronically and understand/agree that my electronic signature has the force and effect of a wet, handwritten signature.

Qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, disability, veteran status, or other characteristics/activities protected by law.

If you wish to obtain a printed copy of your application, please print this page before clicking on the 'Agree' button below.