Work Reference

"*" indicates required fields

Helios Home Health - Reference Request
credentials@helioshomehealth.com | T: 954-566-8922 F: 954-561-7985
Please provide the name of an Agency, Registry, Facility or Private Patient
for whom you have worked that we may contact as a reference.
MM slash DD slash YYYY
MM slash DD slash YYYY
Position Held
May We Contact?*
Caregiver’s Authorization to Release Information
I hereby release from any, and all liability the company or people named above and authorize them to release all information regarding my employment relationship with them.
MM slash DD slash YYYY
Information from Former/Current Employer
The above-named Individual is registering for assignments as an independent Contractor with our organization and authorized you to provide information regarding past performance. Please assist us in our effort to do a thorough screening of all our registrants. This information will be held in strict confidence. Thank you for your prompt reply.
Active Dates:
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.