Employment — Hillcrest Family Clinic

Applicant Information

Full Name *

Date of Birth *

Phone *

Email *

Address

City

State

ZIP

Position

Date Available

Employment Desired

Full-Time Part-Time

Upload Resume

Accepted file types: PDF, DOC, or DOCX.

Experience

Do you have medical office experience?

Yes No

Do you have front desk/reception experience?

Yes No

Have you used an EMR/EHR system?

Yes No

Have you verified insurance?

Yes No

Have you scheduled patient appointments?

Yes No

Have you handled patient payments/copays?

Yes No

Have you worked with confidential patient information?

Yes No

EMR/EHR Systems Used

Employment History

Most Recent Employer

Employer

Position

Dates

Reason for Leaving

Previous Employer

Employer

Position

Dates

Reason for Leaving

Education

Highest Level Completed

High School/GED College Technical/Medical Training

School

Degree/Certification

About You

Why would you like to work at Hillcrest Family Clinic?

What qualities would you bring to our front desk team?

References

Reference 1

Name

Phone

Relationship

Reference 2

Name

Phone

Relationship

Applicant Certification

I certify that the information provided on this application is true and complete to the best of my knowledge. I understand that false or misleading information may affect my eligibility for employment.

I certify that the information provided is true and complete. *

Electronic Signature *

Date *

Employment Application

Applicant Information

Experience

Employment History

Most Recent Employer

Previous Employer

Education

About You

References

Reference 1

Reference 2

Applicant Certification

YOUR HEALTH. YOUR FAMILY. YOUR CLINIC

Hillcrest family clinic

Hours