Apply for HIM Specialist

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Summary
Title:HIM Specialist
ID:5748
Department:Health Information Management
Salary Range:N/A
Employment Status:Full-time
Resume
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Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
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* Zip:
* Phone:
* Email:
Opt-In Confirmation
By submitting this application, I consent to receive SMS updates from Tri-County Mental Health, DBA Beacon Mental Health at 8778392634 regarding my employment application. My information will not be shared or used for any other purposes. This application is powered by ApplicantStack on behalf of Tri-County Mental Health, DBA Beacon Mental Health. SMS messages will only be sent by Tri-County Mental Health, DBA Beacon Mental Health and are used exclusively for hiring-related communications when you have subscribed to receive SMS communications.
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Application for Employment
PERSONAL INFORMATION
* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment):
Yes   No
* Are you at least 18 years or older? (If no, you may be required to provide authorization to work):
Yes   No
* Have you ever worked for this Company before?:
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If Yes, please provide details (Where/When/Job Title):
* Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?:
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If no, please explain:
* Are you willing to work overtime?:
Yes   No
* If driving is a requirement of the job for which you are applying, do you have a valid driver’s license and reliable transportation?:
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* Were you referred for this position by a current  Beacon Mental Health?:
Yes   No
If yes, by whom?:

EMPLOYMENT DESIRED
* When would you be available to begin work?:
* Type of employment desired:
Full-Time
Part Time
Seasonal
* Are you currently employed?:
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If so may we inquire of your present employer?:
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If presently employed, why are you considering leaving?:

EDUCATION
Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School Name & Location Did you Graduate? Degree Received Subjects Studied/Major
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If you have completed any special courses, seminars and/or training that would help you to perform the position for which you are applying, please describe:

EMPLOYMENT HISTORY
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EMPLOYER 1

Dates Employed Employer Name & Address Employer Phone
From:
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To:
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Job Title Supervisor Name & Title May we Contact?
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Yes
No
Responsibilities Reason for Leaving
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EMPLOYER 2

Dates Employed Employer Name & Address Employer Phone
From:
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To:
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Job Title Supervisor Name & Title May we Contact?
*
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*
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Yes
No
Responsibilities Reason for Leaving
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EMPLOYER 3

Dates Employed Employer Name & Address Employer Phone
From:

To:
Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving

REFERENCES Please provide three professional references (not relatives or friends).

Name Relationship Phone Number Email
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AUTHORIZATION
By signing this application, I understand that if hired by the company, I will be an employee at will. This means my employment with the company may be terminated at any time at the option of the company or me. I also understand that neither this application nor any communication by a management representative is intended to create or does in fact create a contract of employment.

I agree to conform to the rules and regulations of the company, and I understand that the company has complete discretion to modify such rules and regulations at any time, except that it will not modify its policy of employment at will.

The above information is complete and true to the best of my knowledge. I understand that any misrepresentation or omission on my part of the facts in this application may result in immediate dismissal.

I hereby authorize the company to conduct any investigation deemed necessary concerning any part of my background related to the position I am seeking. In consideration for the company’s review and evaluation of my application for employment (and the company’s offer of employment, if one is made), I release all parties from any liability in connection with the provision and use of any information obtained in such investigation.

I understand that I am required to abide by all rules and regulations of the company.

* Signature (type name):
* Date:
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
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Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond
Veteran Status: (Please check all that apply)
Individual with a Disability
An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
Vietnam Era Veteran
A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
Disabled Veteran
1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
War/Campaign/Expedition Veteran
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
Armed Forces Service Medal Veteran
A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
Recently Separated Veteran
Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
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