Center I Telemedicine

Application Information

Name Mixter, Ingrid Primary Phone 786-***-**** [Cell]

Secondary Phone (n/a) Date of Application 09-28-2022 Application ID 483224 Email Address ************@*******.*** Address 14485 SW 27 street City, State, Zip Code,

Country

miami, FL, 33175, USA

County DADE Referral Source (n/a)

Referral Name (n/a) Driver's License

Number

(n/a)

Driver's License State (n/a) License Expiration Date (n/a) Education

Institution UNAN, Leon,

Nicaragua,University,(n/a)NIC,

Dates Attended 07/19/1975 - 06/19/1981

Attended As (n/a) Major/Minor (n/a)

Degree MD GPA (n/a)

Graduated No

Employment

Employer ALEXIS SCHLOETER, 180 NW 62 nd

St, Miami, FL, 33150, USA, (786) 360-

5625

Dates of Employment 11/20/2021 To Present

10 Months 8 Days

Job Title / Pay Rate Medical Director

$0.00/

Job Duties Take care of patients, supervise nurse

practicioners

Can Contact? Yes Reason for Leaving (n/a)

Current Employer Yes

References

Name Edwin Herrera Company MD Now

Title Physician Relationship colleague

Email Address (n/a) Time Known 10 years months

Phone 305-***-****

Questions

SANITAS MEDICAL CENTERS

GROUP

Client:

Application for Primary Care Physician (Telemedicine) - 483224

Generated (9/28/2022 10:59 PM) Page 1 of 3

Question Group 1

Are you 18 years of age or older? Yes

Do you have reliable transportation? Yes

Can you provide the necessary documentation to prove that you are a U.S. citizen, permanent resident, or a foreign national with authorization to work in the United States?

Yes

If extended a job offer, are you willing to submit to a detailed background check and drug screen?

Yes

Question Group 2

What is your expected salary range ? 100

When are you available to start ? 10-03-2022

Are you NOW legally authorized to work in the country where the position you are applying for is located? Proof of eligibility for employment is required upon hire. Yes

Do you now, or will you in the future, require sponsorship for an employment visa in the country where the position you are applying for is located? No

Have you ever worked for any Sanitas Medical Center Facility, entities or have any relatives who have?

No

If yes, please specify facility name, dates and Sanitas job titles. If no, enter N/A n/a Have you ever been convicted of any crime or pleaded guilty or had adjunction withheld for any crime?

No

If yes, please explain details. If no, enter N/A. n/a Have you ever been reported to any Federal Regulatory Agency for alleged improper conduct? If yes, please explain in detail.

no

Are you 18 years or older? Yes

Are you willing to work weekends and/or holidays? Yes Are you Bilingual in both English and Spanish? Yes Do you have another source of employment? If yes, please provide name of company/ organization, frequency in which work is done, job title and job functions.If yes, do you intend to maintain this employment while working with Sanitas?If no, please list N/A.

n/a

Are you fully vaccinated against COVID-19? Yes

If no, are you willing to get vaccinated prior to or within the first 90 days of employment and/or documentation to prove you have a qualifying medical or religious exemption?

Yes

SANITAS MEDICAL CENTERS

GROUP

Client:

Application for Primary Care Physician (Telemedicine) - 483224

Generated (9/28/2022 10:59 PM) Page 2 of 3

Question Group 3

Do you have an active state license for the role you are applying for ? Yes If yes, please provide your license number. If no, enter N/A. ME 96827 Do you have the required certifications for the job you are applying for ? No If yes, please provide your certification number. If no, enter N/A N/a Statement

I certify that all employment information given to Sanitas Medical Center. by me in this application form is full, true and correct to the best of my knowledge. I understand that falsification of information, including omission of any information sought, may lead to termination of my employment, refusal to hire me or withdrawal of employment offer. I hereby authorize all previous employers and references to give you any and all information about my prior employment (excluding medical inquiries) including performance, conduct and reason(s) for leaving employment and release them from liability for any damage that may result from furnishing such information to Sanitas Medical Center. Upon my termination I authorize the release of reference information by Sanitas Medical Center on my work in response to any reference request that may be received. Upon termination of my employment, I authorize Sanitas Medical Center to make all lawful deductions from my final paycheck for all company property in my possession, which is not returned to the in good condition. I understand that my employment with Sanitas Medical Center is for no definite period of time and that I may terminate my employment at any time, and for any reason, and that Sanitas Medical Center may do the same. This understanding cannot be changed verbally by anyone and may only be changed in writing if signed by the Administrator of Sanitas Medical Center I understand that Sanitas Medical Center cannot guarantee work hours and that as business conditions dictate I may be required to work on shifts other than those for which I was originally employed. In addition, I understand that I may be requested to perform other duties that I am qualified for in addition to or instead of the duties of the job, which I was hired for, if the company deems necessary. I acknowledge the right if Sanitas Medical Center require employees to submit to polygraph examinations in accordance with the Employee Polygraph Protection Act of 1988, and property searches in connection with any investigation of theft, misappropriation, acts of dishonesty, or other illegal acts at the company and I hereby consent to submit to such examination in the event I am requested to do so by the company management in connection with such an investigation. In compliance with the 1986 Immigration Reform Act, the company will require the completion of the Form I-9 after the offer of employment.

If offered employment, I authorize any healthcare provider to release all information necessary for Sanitas Medical Center to determine my ability to safety and efficiently perform specific job duties now or in the future. Current regions: South Florida, Central Florida, West Florida, New Jersey, Connecticut, Texas and Tennessee. Acknowledged

Yes

Signature

Ingrid Mixter [09/28/2022]

SANITAS MEDICAL CENTERS

GROUP

Client:

Application for Primary Care Physician (Telemedicine) - 483224

Generated (9/28/2022 10:59 PM) Page 3 of 3

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