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New Hire Forms
Physician Recruitment
New Hire Forms
New hires are asked to complete necessary paperwork prior to their scheduled processing appointment with Human Resources. Please print the forms and complete the necessary information. Bring the completed forms to your appointment with Human Resources for processing and pre-placement screening. Forms include:

Firelands Regional Medical Center Hires:
  1. Form I-9: Employment Eligibility Verification Form
    Please bring the following to your processing appointment:
    • Ohio Driver’s License and
    • Social Security Card or Birth Certificate or U.S. Passport
  2. Policy Manual Acknowledgement Form
  3. Form W-4: Federal Income Tax Form
  4. Form IT-4: Ohio Taxation Form
  5. Direct Deposit Enrollment
  6. Enrollment/Change Form (Application for Health Insurance)
    Please bring the following to your processing appointment:
    • Proof of Spouse – Marriage Certificate or Tax Documentation
    • Natural-Born Children and Step-Children – Birth Certificate, Hospital Certificate or Tax Documentation
    • Adopted Child – Final Adoption Papers or Tax Documentation
  7. Pre-Tax Health Insurance Premium Plan Enrollment Form and Authorization for Payroll Deduction
  8. AD&D Insurance Enrollment Form
  9. Employee Safe Driving Guidelines
  10. Parking Registration Form
  11. 10-Hour Shift Agreement
  12. 12-Hour Shift Agreement
  13. PYXIS Medstation 2000/3500 ID/Password/Bio-ID Assignment
  14. Employee Emergency Information Form
  15. Request to Access Firelands Computer Resources
  16. What to expect at your visit to Firelands Corporate Health Center
Firelands Physician Group Hires:
  1. Form I-9: Employment Eligibility Verification Form
    Please bring the following to your processing appointment:
    • Ohio Driver’s License and
    • Social Security Card or Birth Certificate or U.S. Passport
  2. Form W-4: Federal Income Tax Form
  3. Form IT-4: Ohio Taxation Form
  4. Direct Deposit Enrollment Form
  5. Health Insurance Enrollment Form
    Please bring the following to your processing appointment:
    • Proof of Spouse – Marriage Certificate or Tax Documentation
    • Natural-Born Children and Step-Children – Birth Certificate, Hospital Certificate or Tax Documentation
    • Adopted Child – Final Adoption Papers or Tax Documentation
  6. Pre-Tax Health Insurance Premium Plan Enrollment Form and Authorization for Payroll Deduction
  7. Life and AD&D Insurance Enrollment Form
  8. Employee Safe Driving Guidelines
  9. Employee Emergency Information Form
  10. Request to Access Firelands Computer Resources
  11. Confidentiality Form
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#1 in Ohio in Spine Surgery
Providing the best quality care and the best possible outcomes, in the best imaginable location – close to home. For excellence in Spine Surgery and beyond, choose Firelands.

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About Us
Firelands Regional Medical Center is committed to being big enough to care FOR you, and small enough to care ABOUT you.  With our advanced regional care, Firelands Regional Medical Center offers the following core services to you and your family:
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Firelands Regional Medical Center 1111 hayes ave. Sandusky, Ohio 44870 419-557-7400, 800-342-1177 Contact us
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For questions about charitable giving to Firelands Regional Medical Center please contact charitable.gift@firelands.com