BSM Connection™
Prototype Manual
Prototype Policy and
Procedure Manual
INSTRUCTIONS FOR USE
This sample Prototype Policy and Procedure Manual is intended to assist you in
customizing your own employee handbook and is provided with the caveat that your
Practice handbook may be more specific than the one provided herein since policies
vary based on state law, the size of your practice group, the number of employees,
benefits offered, and various other factors. Therefore, this handbook is intentionally
broad and should be supplemented and modified according to the needs of your
Practice. The informational boxes that appear at the end of various sections of this
handbook are for the employer’s information and should be removed before the
handbook is distributed to employees.
While the information provided in this handbook is intended to be complete and
accurate, it is not intended to be legal advice. Employment laws vary by state; this
handbook does not specifically cover the laws of your state. BSM Consulting is not
responsible for any errors or omissions. BSM Consulting is not supplying legal or
professional advice in distributing this handbook.
The guidance of an attorney familiar with your state’s laws is essential in creating an
effective and accurate employee handbook. Contact an employment attorney licensed
to practice in your area for state-specific information. For assistance in finding an
attorney, contact the American Bar Association at 1-800-285-2221.
© 2007, BSM Consulting
All Rights Reserved.
Sample
PROTOTYPE POLICY
AND PROCEDURE MANUAL
{Practice Name}
TABLE OF CONTENTS
ACKNOWLEDGEMENT OF RECEIPT ...................................................................................... 1
INTRODUCTION ....................................................................................................................... 1
Purpose of the Practice .................................................................................................. 1
Purpose of this Handbook .............................................................................................. 2
At-Will Employment ........................................................................................................ 2
WORKPLACE COMMITMENTS ................................................................................................ 3
Equal Opportunity Employment ...................................................................................... 3
Harassment/ Non-Discrimination Policy .......................................................................... 3
Open Door Policy ........................................................................................................... 4
PRACTICE POLICIES AND PROCEDURES ............................................................................ 5
Uniforms ......................................................................................................................... 5
Personal Appearance ..................................................................................................... 5
Smoking ......................................................................................................................... 5
Personal Phone Calls ..................................................................................................... 5
Cell Phone Usage .......................................................................................................... 5
Electronic Media and Services ....................................................................................... 5
Personnel Files............................................................................................................... 6
EMPLOYEE CLASSIFICATION ................................................................................................ 7
Probationary Employees ................................................................................................ 7
Regular Full-Time Employees ........................................................................................ 7
Regular Part-Time Employees ........................................................................................ 7
Temporary Employees ................................................................................................... 7
Per-Diem Employees...................................................................................................... 7
On-Call Employees......................................................................................................... 7
WORKING HOURS, BREAKS, AND TARDINESS POLICIES .................................................. 8
Working Hours................................................................................................................ 8
Breaks ............................................................................................................................ 8
Tardiness ....................................................................................................................... 8
EMPLOYEE BENEFITS ............................................................................................................ 9
Medical/ Dental/ Life Insurance Coverage ...................................................................... 9
Retirement Plan.............................................................................................................. 9
Workers’ Compensation ................................................................................................. 9
Continuing Education ....................................................................................................10
Vacations ......................................................................................................................10
Sick Leave .....................................................................................................................11
Holidays ........................................................................................................................11
Personal Time Off .........................................................................................................11
Funeral Leave ...............................................................................................................11
Leave for Performance of Civic Duties...........................................................................12
Military Leave ................................................................................................................12
Leave of Absence ..........................................................................................................12
Family and Medical Leave Act (“FMLA”) Leave .............................................................13
COMPENSATION POLICIES ...................................................................................................15
Pay Periods ...................................................................................................................15
Recording of Time .........................................................................................................15
Overtime Pay.................................................................................................................15
Double-Time ..................................................................................................................16
Weekends .....................................................................................................................16
Holidays Worked ...........................................................................................................16
STANDARDS OF CONDUCT ...................................................................................................17
Expectations ..................................................................................................................17
Performance Evaluation ................................................................................................17
Grounds For Disciplinary Action ....................................................................................17
TERMINATION .........................................................................................................................19
COBRA Continuation of Health Benefits ........................................................................19
DRUG/ALCOHOL ABUSE .......................................................................................................20
ORGANIZATIONAL CHART ....................................................................................................21
ACKNOWLEDGEMENT OF RECEIPT
* This is the employee’s copy. Keep this copy with the handbook.
I acknowledge that I am in receipt of [Practice Name] policy manual and understand that
it contains important information about the Practice’s policies and procedures. I
understand that I am expected to read this manual, familiarize myself with the material,
and adhere to the policies that are outlined in the manual.
I understand that this handbook is intended to provide me with a general overview of the
Practice’s policies and procedures. I acknowledge that nothing in this handbook is to be
interpreted as a contract, express or implied, or an inducement for employment, nor
does it guarantee my employment for any period of time.
I understand and accept that my employment with the Practice is at will. I have the right
to resign at any time with or without cause, just as the Practice may terminate my
employment at any time without cause or notice, subject to applicable laws. I
understand that nothing in the handbook or in any oral or written statement alters the atwill relationship, except by written agreement signed by the employee and [enter
authorized person’s name].
I understand that the Practice can change, rescind, or add to the policies, benefits or
practices as described in the manual at its sole and absolute discretion (with or without
prior written notice). It is my understanding that the Practice will attempt to provide
adequate notice before any new policies or procedures are put into effect, but it is not
required to do so. I understand that I am personally responsible for keeping my
orientation manual current with policy updates.
_________________________________________
Employee’s Signature
_____________________
Date
_________________________________________
Signature of Practice Representative
_____________________
Date
ACKNOWLEDGEMENT OF RECEIPT
* This is the employer’s copy. Detach this copy and retain for records.
I acknowledge that I am in receipt of [Practice Name] policy manual and understand that
it contains important information about the Practice’s policies and procedures. I
understand that I am expected to read this manual, familiarize myself with the material,
and adhere to the policies that are outlined in the manual.
I understand that this handbook is intended to provide me with a general overview of the
Practice’s policies and procedures. I acknowledge that nothing in this handbook is to be
interpreted as a contract, express or implied, or an inducement for employment, nor
does it guarantee my employment for any period of time.
I understand and accept that my employment with the Practice is at will. I have the right
to resign at any time with or without cause, just as the Practice may terminate my
employment at any time without cause or notice, subject to applicable laws. I
understand that nothing in the handbook or in any oral or written statement alters the atwill relationship, except by written agreement signed by the employee and [enter
authorized person’s name].
I understand that the Practice can change, rescind, or add to the policies, benefits or
practices as described in the manual at its sole and absolute discretion (with or without
prior written notice). It is my understanding that the Practice will attempt to provide
adequate notice before any new policies or procedures are put into effect, but it is not
required to do so. I understand that I am personally responsible for keeping my
orientation manual current with policy updates.
_______________________________________
Employee’s Signature
_____________________
Date
_______________________________________
Signature of Practice Representative
_____________________
Date
1
INTRODUCTION
PURPOSE OF THE PRACTICE
The ultimate purpose of this Practice is to provide the highest quality of care to our patients.
This commitment to the highest quality of care is paramount in this Practice. We want to provide
the best health care possible, and we want to do that in the proper environment. In addition to
having the proper facility and equipment, we are dedicated to hiring the right personnel of the
highest quality. With the right personnel, equipment, and facility, we are able to provide
excellence in treating our patients.
As employers, we welcome the responsibility to provide a work environment that allows our
employees to be happy and to grow. We have made every attempt to be fair in our hiring
practices, and that doctrine of fairness is one for which we shall strive in our relationship with
each employee.
We are dedicated to providing a safe and positive work environment for employees. When you
are bothered by something in your environment, we want you to feel free to tell us, and we will
listen. We are committed to open communications and expect you to participate in seeking
improvements that result in better patient care and more efficient ways of doing things.
The Practice is organized to provide the best possible medical care to the patient. Due to the
demands on physician time, the Practice will delegate authority to the practice manager. The
practice manager reflects the policies of the Practice and needs your cooperation, just as the
physician does.
We work as a team. Whether your job is working directly with patients or strictly clerical, the
tasks performed contribute to the quality of patient care. Each team member needs to be
supportive of the others. Your job is an important one.
We are here for a common purpose. Your role is important! What you say, what you do, and
how you do it should contribute substantially to the care of the patient. Remember our goal:
THE HIGHEST QUALITY OF CARE TO OUR PATIENTS!
1
PURPOSE OF THIS HANDBOOK
The contents of this handbook are presented as a matter of information only. While [Practice
Name] believes in the plans, policies, and procedures described here, they are not conditions of
employment. This handbook provides an overview of the work environment and is not intended
to be an all-inclusive or strict interpretation of the Practice’s policies. It is designed to tell you
what the Practice expects from you, and what you can expect from us. The structure allows for
a lot of routine things to happen automatically and eliminates misunderstandings.
The Practice reserves the right to modify, revoke, suspend, terminate, or change any and all
such plans, policies, or procedures, in whole or in part, at any time, with or without notice. This
handbook supersedes and replaces all personnel policies and manuals previously distributed,
made available or applicable to employees.
AT-WILL EMPLOYMENT
The language used in this handbook is not intended to create nor is it to be construed to
constitute a contract, express or implied, guarantying employment for any length of time. All
employees are reminded that they are considered employees at will and may be terminated
without cause or notice at any time. This at-will relationship exists regardless of any statements
by office personnel to the contrary. Only [insert authorized person’s name] is permitted to
modify the at-will relationship between the Practice and an individual employee, and the
modification must be in writing.
Some states limit the terms of at-will employment. Consult with an employment attorney regarding your
state’s laws.
2
WORKPLACE COMMITMENTS
EQUAL OPPORTUNITY EMPLOYMENT
[Practice Name] is an equal opportunity employer. It is the policy of the Practice to recruit, hire,
place, compensate, promote, discipline, and terminate employees in a manner which does not
discriminate against any individual because of race, color, religion, creed, marital status, veteran
status, national origin, sex, age, disability, or any other status protected by applicable law. The
Practice will make reasonable accommodations for qualified individuals with disabilities to the
extent required by law. Employees who would like to request a reasonable accommodation
should contact [enter authorized person’s name].
Workplace discrimination is prohibited by several federal laws that are enforced by the U.S. Equal
Opportunity Commission. Employers should include any statements in this section that are required
by more stringent state and/or local laws, such as those laws that recognize additional protected
classes beyond those protected by federal laws.
HARASSMENT/ NON-DISCRIMINATION POLICY
In keeping with the Practice’s policy of equal opportunity employment, the Practice will not
tolerate any form of discrimination or harassment based on race, color, creed, religion, sex,
national origin, age, disability, marital status, veteran status or any other status protected by
applicable law. Violations of this policy will not be tolerated.
Discrimination includes, but is not limited to making an employment decision or taking an
employment-related action based on any of the protected statuses enumerated above.
Harassment is unwelcome verbal or non-verbal conduct based upon a person’s protected
characteristics and which affects a person’s employment opportunities or benefits, has the
purpose or effect of unreasonably interfering with the person’s work performance, or has the
purpose or effect of creating an intimidating, hostile or offensive working environment.
Harassing conduct includes, but is not limited to: epithets; slurs or negative stereotyping;
threatening, intimidating or hostile acts; and denigrating jokes and display or circulation in the
workplace of written or graphic material that denigrates or demonstrates hostility or aversion
toward an individual or group based on their protected characteristic.
Sexual harassment is defined as unwelcome sexual advances, requests for sexual favors and
other verbal, visual or physical conduct of a sexual nature, when either:
1. Submission to such conduct is made either explicitly or implicitly a term of an individual’s
employment;
2. Submission to or rejection of such conduct by an individual is used as a basis for
employment decisions affecting such an individual; or
3. Such conduct has the purpose or effect of unreasonably interfering with an individual’s
work performance or creating an intimidating, hostile, or offensive work environment.
Examples of sexual harassment include, but are not limited to: unwelcome or unsolicited sexual
advances; displaying sexually suggestive material; unwelcome sexual flirtations, advances or
propositions; suggestive comments; verbal abuse of a sexual nature; sexually oriented jokes;
3
crude or vulgar language or gestures; graphic or verbal commentaries about an individual’s
body; display or distribution of obscene materials; physical conduct such as patting, pinching or
brushing against someone’s body; and physical assault of a sexual nature.
Any employee who observes or is involved in harassing or discriminatory actions should report
the incident to the practice manager immediately. If the employee’s immediate supervisor is the
source of the alleged harassment, the employee should report the problem to the practice
manager. The Practice will promptly investigate all such allegations and take action as
appropriate based on the outcome of the investigation. The investigation and its results will be
treated as confidential to the extent possible.
The Practice will not retaliate against an employee who makes a complaint in good faith
regarding a violation of these policies, or for participating in good faith in an investigation
pursuant to these policies. If an employee feels that he/she has been retaliated against, the
employee should file a complaint using the procedures set forth above.
OPEN DOOR POLICY
The Practice has an open door policy and takes employee concerns and problems seriously.
The Practice values each employee and strives to provide a positive work experience.
Employees are encouraged to bring any workplace concerns or problems they might have or
know about to their supervisor, practice manager, or some other member of management.
4
PRACTICE POLICIES AND PROCEDURES
UNIFORMS
The Practice will provide scrubs for medical personnel, including RNs and technicians. Those
employees who are provided scrubs are expected to wear them on a daily basis. Upon
termination, the employee is expected to return the scrubs to the Practice.
PERSONAL APPEARANCE
An employee’s personal appearance and hygiene is a reflection on the Practice. Employees
are expected to dress appropriately for their individual work responsibilities and position.
Medical staff should wear a lab coat or uniform at all times.
SMOKING
There will be no smoking in the office or at the visitor entrances to the building.
PERSONAL PHONE CALLS
This office permits certain limited personal calls. Calls to arrange transportation, to check on the
safety of immediate family members, and other such calls can be made provided that they are
brief. They must be local calls and must be made at a time when they do not interfere with your
work and may not cause you to fall behind in your duties. Incoming calls must be kept extremely
short. These calls are discouraged.
All personal calls must be made out of hearing range of patients. Our patients need your full
attention.
CELL PHONE USAGE
The Practice discourages the use of personal cell phones while working. The use of cell phones
during breaks is to be restricted to the break room only.
The office reserves the right, in its discretion, to restrict any employee's cell phone use during
business hours to the extent necessary to ensure work efficiency and to comply with Practice
policies. Any employee found to be abusing the cell phone policy will be subject to disciplinary
action.
ELECTRONIC MEDIA AND SERVICES
Employees may have access to one or more forms of electronic media and services (i.e.,
computers, e-mail, online services, and the Internet). The Practice encourages the use of these
media and associated services because they make communication more efficient and effective
and are valuable sources of information. However, electronic media and services provided by
the Practice are Practice property, and their purpose is to facilitate Practice business.
5
The following conditions apply to all electronic media and services that are accessed on or from
the premise of the Practice; accessed using Practice computer equipment, or via Practice-paid
access methods; and/or used in a manner that identifies the individual with the Practice:

Electronic media may not be used for knowingly transmitting, retrieving, or storing any
communication of a discriminatory or harassing nature, or which is derogatory to any
individual group, or which is obscene or X-rated, or of a defamatory or threatening
nature, or for “chain letters,” or for any other purpose which is illegal or against Practice
policy or contrary to the Practice’s interest.

Electronic media and services are primarily for business use. Limited, occasional, or
incidental use of electronic media (sending or receiving) for personal, non-business
purposes is acceptable, as is the case with personal telephone calls; however,
employees may not abuse the privilege.

The Practice reserves the right, in its discretion, to review any employee’s electronic
files, messages and usage to the extent necessary to ensure that electronic media and
services are being used in compliance with the law and with this and other Practice
policies. Employees should not assume electronic communications are private or
confidential and should transmit highly sensitive information in other ways. Any
employee found to be abusing access to electronic media or services will be subject to
disciplinary action.
Privacy laws are relatively new and vary from state to state. Consult with an employment attorney
regarding your state’s privacy laws.
PERSONNEL FILES
The Practice maintains a personnel file on each employee. These files are kept confidential to
the extent possible. Employees may review their personnel file on request.
It is important that personnel files accurately reflect each employee’s personal information.
Employees are expected to inform the Practice of any change in name, address, home phone
number, home address, marital status, number of dependants, or emergency contact
information.
Employers should consult state and local law regarding any provisions relating to employee access to
personnel files. In the absence of such a provision, the Practice may not be required to allow employees
to have access to their personnel files. However, the Practice may nonetheless allow employees to have
access. In the event that the Practice allows employee access, the Practice may want to consider
limiting the access to appointment only during normal business hours.
6
EMPLOYEE CLASSIFICATION
PROBATIONARY EMPLOYEES
The first ninety (90) calendar days of your employment with the Practice is considered to be
your probationary period. The Practice reserves the right to extend this period whenever it
deems such an extension appropriate.
This ninety-day (90) probationary period does not affect the employee’s status as an at-will
employee, and hence, the employee may be terminated at any time with or without cause.
Either you, on two (2) weeks notice, or the Practice reserve the right to terminate the
employment relationship at any time, with or without cause.
REGULAR FULL-TIME EMPLOYEES
An employee who regularly works a minimum of forty (40) hours per week on a continuing
basis, and who has completed the probationary period, is considered to be a regular full-time
employee.
REGULAR PART-TIME EMPLOYEES
An employee who regularly works less than forty (40) hours per week, and who has completed
the probationary period, is considered to be a regular part-time employee.
TEMPORARY EMPLOYEES
A temporary employee may be hired to work on a part-time or full-time basis, but generally is
scheduled to terminate his or her employment by a certain date. Temporary employees who
remain on duty past the scheduled termination remain classified as temporary. Only [enter
authorized person’s name] may change an employee’s temporary status. Temporary employees
are not eligible for employment benefits.
PER-DIEM EMPLOYEES
Per-diem employees are temporary employees and are called on by the Practice on an asneeded basis. The per-diem status affords flexibility in the individual’s work schedule and
allows the Practice to fulfill specific needs on a daily basis.
ON-CALL EMPLOYEES
On-call employees are defined as those employees who are not scheduled to work on a regular
basis but work only as needed and as called in. On-call employees are temporary employees,
and as a result are ineligible for any employer-sponsored benefits.
Since all employees are hired for an unspecified duration, these classifications do not guarantee
employment for any specific length of time. Employment is at the mutual consent of the
employee and the Practice. Accordingly, either the employee or the Practice can terminate the
employment relationship at will.
7
WORKING HOURS, BREAKS, AND TARDINESS POLICIES
WORKING HOURS
Except for those employees with divergent schedules, the normal workweek will be Monday
through Friday, based on a forty-hour (40) week. These hours will be set by the practice
manager to ensure that the office is sufficiently staffed to support the physician(s) in the
Practice. Hours may vary depending on work location and job responsibilities.
The normal hours in the office are from 8:30 a.m. to 5:00 p.m., Monday through Friday;
however, this is subject to change, and the office staff must remain flexible to support the
physician(s). The practice manager will provide employees with their work schedules. Should
an employee have a question regarding his/her work schedule, he/she should contact the
practice manager. If you, as an employee, are scheduled to work hours that present a hardship,
you should discuss this with your supervisor and the practice manager.
There are many other obligations maintained by the physician(s) besides seeing patients in the
office. As various support functions for these activities are determined, some staff scheduling
changes will also be required. We ask you to remain as flexible as possible if changes in the
normal schedule are required. We will certainly discuss these requirements with you as far in
advance as possible.
BREAKS
You will be entitled to a lunch period. Since the usual lunch period is also a peak in patient
activity, it will be necessary to stagger individual lunch periods so that proper care for the
patients will be provided. You are expected to take a 30-minute lunch break. If you choose to
remain in the office during the meal break, you are not expected to work except under the most
unusual circumstances. You are entitled to take [enter number] [enter time] minute breaks for
every [enter hours] worked.
The laws regarding break and meal periods are different in each state. Consult with an employment
attorney regarding your state’s laws.
TARDINESS
Tardiness is unacceptable. If for any reason you cannot report for work on time, telephone the
office and inform your immediate supervisor or the practice manager of your status. Do not
leave a message with a fellow employee. An employee who arrives [enter time period] after their
scheduled arrival time is considered tardy. The Practice recognizes that situations arise that
may hinder punctuality; however, excessive tardiness is prohibited and may result in disciplinary
action.
8
EMPLOYEE BENEFITS
The following represents a current list of employment benefits offered by the Practice:

Insurance Benefits

Retirement Plan Participation When Eligible

Paid Holidays

Paid Personal Time Off

Paid Vacation Days

Paid Sick Days

Continuing Education Funds

Others as Described in This Section
MEDICAL/ DENTAL/ LIFE INSURANCE COVERAGE
The details of our current insurance benefits, including employee eligibility, are described in
more formal plan documents that are available from [enter name]. In the event of any
inconsistencies between this handbook or any other written or oral description of benefits and a
formal plan document, the formal plan document will govern.
Insurance coverage becomes effective on the first day of the month following employment for
one full calendar month. Coverage is available to eligible employees at no cost to the employee.
However, the employee is responsible for the cost of dependent coverage.
RETIREMENT PLAN
Please refer to the formal plan documents for specific details, including employee eligibility,
regarding the Practice’s retirement plan. The details discussed in the plan documents include
eligibility requirements, the types of plans available, the vesting period, etc. In the event of any
inconsistencies between this handbook or any other written or oral description of benefits and a
formal plan document, the formal plan document will govern.
Participation in the pension and profit sharing plan will commence on the first entry date
following twelve (12) months of full-time employment by eligible employees with the Practice.
Terms of participation will be the same for all eligible employees, and continued maintenance of
the plan is at the discretion of the Practice.
WORKERS’ COMPENSATION
As required by law, the Practice provides workers’ compensation benefits for the protection of
employees with work-related injuries or illnesses.
Workers’ compensation insurance provides coverage to employees who are injured or become
ill while working. If the injury or illness is a result of the employee’s job, it is the employee’s
responsibility to immediately notify a supervisor of the injury in order to be eligible to receive
9
benefits. Report every illness or injury to a supervisor, no matter how minor it may seem. The
Practice will advise the employee of the procedure for submitting a workers’ compensation
claim. If necessary, injured employees will be referred to a medical care facility. Employees
should retain all paperwork provided to them by the medical facility. Failure to report a workrelated illness or injury promptly could result in the denial of benefits. An employee’s report
should contain as many details as possible, including the date, time, description of the illness or
injury, and the names of any witnesses.
A separate insurance Practice administers the workers’ compensation insurance, and that
Practice might contact injured employees regarding their benefits under the plan.
CONTINUING EDUCATION
Continuing education is encouraged for all employees. The Practice will send employees to
training seminars on occasion. Home study courses are also available to all full-time employees
as an employment benefit. This is meant to further train staff in specialties associated with this
Practice.
Upon receiving full-time status, each employee shall be allowed up to [insert dollar amount] per
anniversary year for continuing educational course fees and travel expenses.
VACATIONS
Eligible employees are granted the following number of days of paid vacation leave based upon
the length of continuous active service to the Practice:

Years 1-4:
2 weeks (10 days)

Years 5-9:
3 weeks (15 days)

Years 10+:
4 weeks (20 days)
An employee is eligible to take paid vacation leave following three (3) months of employment.
Vacation days may be taken in full-day or half-day (four-hour (4)) increments. We prefer that
vacations be taken when the physician(s) is out of town or on vacation.
Employees should forward requests for use of vacation leave to their supervisor. The Practice
is flexible in approving time off when doing so will not interfere with operation of the Practice.
The dates and duration of your vacation leave should be submitted to the practice manager in
writing at least two (2) months in advance. The practice manager will approve or deny the
request based on the Practice resources and in light of other requests for vacation time already
received. In case of a scheduling conflict, the employee who submits the request for utilization
of vacation time first will be given preference.
Since vacations provide a period of needed rest and recreation, each employee is expected to
take his/her allotted vacation during the year in which it is earned. Unused vacation time cannot
be carried over into the next year. The Practice will not reimburse employees for lost vacation
days.
All questions concerning vacations should be directed to the practice manager.
The employer may choose to have vacation leave awarded based on each employee’s anniversary
date or based on a calendar or fiscal year basis. However, vacation leave accrual, the loss of accrued
vacation leave, and the reimbursement of vacation leave upon termination is subject to applicable state
law. The Practice should consult state and local law regarding the treatment of vacation leave.
10
SICK LEAVE
An employee is eligible for sick leave with pay after three (3) months of continuous employment.
Three (3) days of sick leave with pay are accrued each year and may be used in four-hour (4)
increments. Sick time that exceeds the allotted amount will be treated as time off without pay.
Extra time off is not granted for illness during a vacation or on a holiday. A maximum of ten (10)
days of unused sick leave can be carried over to the next year.
In case of any absence due to illness, employees will notify their immediate supervisor or the
practice manager as soon as possible. Do not leave a message with a fellow employee. The
practice manager will maintain the status of sick leave for each employee.
HOLIDAYS
Full-time employees will be paid for each of the following holidays:

New Year’s Day

Memorial Day

Independence Day

Labor Day

Thanksgiving Day

Christmas Day
Employees must work the business days preceding and following the holiday or have the
practice manager approve the absence in order to be paid for the holiday.
The Practice should consult state and local law to determine whether there are any mandated
holidays in the jurisdiction where they are located.
PERSONAL TIME OFF
An employee may utilize up to two and one-half (2 ½) days, or twenty (20) hours, for personal
reasons per year. This time may be taken in half-day (four (4) hour) increments. Personal days
are granted on a paid basis. Personal time off that exceeds the allowed amount will be treated
as time off without pay.
Personal time off should be requested and approved three (3) days in advance. Approval must
be given by the supervisor and/or the practice manager.
FUNERAL LEAVE
Employees will be given up to three (3) days off with pay for regularly scheduled workdays
missed due to the death of an immediate family member. Immediate family members shall be
defined as husband, wife, parent, step-parent, child, step-child, brother, sister, mother-in-law,
father-in-law, son-in-law, daughter-in-law, grandparent or grandchild. Any time in excess of
three (3) days will be counted against vacation, sick leave, and/or personal time, or it will be
taken without pay.
11
LEAVE FOR PERFORMANCE OF CIVIC DUTIES
Any employee who is called to serve on a jury panel, or subpoenaed to serve as a witness in a
court proceeding in which he or she is not a litigant, will be allowed to serve. Employees who
are selected for jury duty or subpoenaed to appear as a witness must provide a copy of their
jury summons or subpoena to a supervisor. Time taken for jury duty is granted on a paid basis
for up to [insert number] weeks.
The voting polls are usually open from early in the morning until late in the evening. It is
expected that you will find time to vote before coming to work or during your personal time after
work. However, if that is not possible, please notify your supervisor or the practice manager in
advance.
Most state laws prohibit an employer from taking any disciplinary action against employees for taking
time off to vote or serve on a jury. Some states even require the time off to be granted on a paid
basis. If your state requires paid jury/voting time off, be sure that the Practice’s policy complies with
those requirements.
MILITARY LEAVE
Employees called to active military duty, military reserve or National Guard service may be
eligible to receive time off under the Uniformed Services Employment and Reemployment
Rights Act of 1994. To receive time off, employees must provide notice and a copy of their
report orders to an immediate supervisor. Military leave is granted on a [paid/unpaid] basis [if
leave is paid, state here the number of days of paid leave to be provided by the Practice.] Upon
return with an honorable discharge, an employee may be entitled to reinstatement and any
applicable job benefits they would have received if present, to the extent provided by law.
All private employers are required to comply with USERRA, which prevents employers from taking
disciplinary action against an employee because of their military status, as well as provides certain
protections for military veterans. For more information on the USERRA, visit the Department of
Labor’s website at http:www.dol/elaws/vets/userra/mainmenus.asp.
LEAVE OF ABSENCE
When it is necessary for an employee to be absent from work for an extended period of time,
the employee may request a leave of absence. An employee must have ninety (90) days of
continuous service before a leave of absence will be considered. All accumulated leave, i.e.,
vacation and sick, must be depleted first. A leave of absence can be requested for reasons of
jury duty, personal illness, pregnancy, or temporary disability, among other reasons.
A request for a leave of absence must be presented to the practice manager in writing in
advance of the requested leave and accompanied by a statement from the attending physician
or a copy of the jury summons necessitating the leave of absence. The request must indicate, to
the best of the employee’s judgment, the length of time the absence will be necessary. The
physician will give final approval on this request.
Approved absences of thirty (30) calendar days or less will be considered excused absences. If
it is necessary for the absence to extend more than thirty (30) calendar days, the absence will
be considered a leave of absence.
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While on excused absence (30 calendar days or less), the employee’s benefits will continue to
accrue and length of service will not be affected. An employee on leave of absence (over 30
calendar days) may arrange to continue his or her health insurance coverage at his or her own
expense.
The employee’s length of service with the Practice will be maintained along with any accrued
benefits up to the date that the leave of absence begins. The employee may not continue
accruing vacation, sick leave, and/or holiday benefits while on leave.
All approved leaves of absence are granted with the stipulation that the employee returning from
leave will accept whatever position is offered for which they may be qualified. In order to return
from a leave of absence taken for medical reasons, the employee must have a written
statement from their private physician and must be able to resume all responsibilities of the
position to be filled.
The Americans with Disabilities Act (“ADA”) applies to employers with 15 or more employees and
prohibits discrimination against qualified disabled employees in regard to medical leave and other
leaves of absence. Accordingly, employers must offer leaves of absence to disabled employees
under the same circumstances that they offer them to non-disabled employees. The ADA also
requires employers to reasonably accommodate a qualified individual with a disability if doing so
would enable the employee to perform the essential functions of the job, unless the accommodation
would impose an undue hardship on the employer’s business. Whether an accommodation
constitutes an undue hardship is determined on a case-by-case basis. Reasonable accommodations
include modified work schedules, flexible leave policies, or unpaid leaves of absence to obtain
treatment or rehabilitation.
FAMILY AND MEDICAL LEAVE ACT (“FMLA”) LEAVE
The Practice offers leave consistent with the requirements of the federal Family and Medical
Leave Act (FMLA). Under the FMLA, an employee may be eligible for an unpaid family and
medical leave of absence under certain circumstances if the employee works within a seventyfive (75) mile radius of fifty (50) or more Practice employees.
Under the FMLA, a person who has worked as an employee of this Practice for at least 1,250
hours for a twelve-month period is eligible for FMLA leave. Up to twelve (12) weeks of unpaid
leave is available for the following reasons:

The birth of a child and to care for a newborn child;

Placement of a child into adoptive or foster care with the employee;

Care for a spouse, son, daughter or parent who has a serious health condition; or

Care for the employee’s own serious health condition.
If the need for leave is foreseeable, employees should notify a supervisor thirty (30) days prior
to taking FMLA leave. If the need for FMLA leave arises unexpectedly, employees should notify
a supervisor as soon as practical, giving as much notice to the Practice as possible.
Employees may be required to provide: medical certifications supporting the need for leave if
the leave is due to a serious health condition of the employee or the employee’s family member;
periodic recertification of the serious health condition; and periodic reports during the leave
regarding the employee’s status and intent to return to work. Employees must return to work
immediately after the serious health condition ceases, and employees who have taken leave
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because of their own serious health condition must submit a fitness-for-duty certification before
being allowed to return to work.
Leave may be taken on an intermittent or reduced schedule to care for an illness. However,
leave may not be taken intermittently for the care of a newborn or newly adopted child. When
leave is taken intermittently, the Practice may transfer the employee to another position with
equivalent pay and benefits, which is better suited to periods of absence.
Subject to certain conditions, the employee or the Practice may choose to use accrued paid
leave (such as sick leave or vacation leave) concurrent with FMLA leave.
The Practice will maintain group health insurance coverage for an employee on FMLA leave on
the same terms as if the employee had continued to work. If applicable, arrangements will be
made for the employee to pay their share of health insurance premiums while on leave. The
Practice may recover premiums paid to maintain health coverage for an employee who fails to
return to work from family and medical leave.
If an employee would like the Practice to maintain other paid benefits during the period of leave,
premiums and charges that are partially or wholly paid by the employee must continue to be
paid by the employee during the leave time.
Family and medical leave will not result in the loss of any employment benefit accrued prior to
the date on which the leave commenced. However, an employee on family and medical leave
does not continue to accrue benefits (e.g., sick or vacation leave) during the period of family and
medical leave. Questions regarding particular benefits should be directed to [enter name].
Upon returning from FMLA leave, an employee will be restored to his/her original job or an
equivalent job with equivalent benefits, pay, seniority, and other employment terms and
conditions as provided by the FMLA.
Companies with 50 or more employees are required to comply with the FMLA. If you are covered,
your manual should contain this FMLA Leave section. For more information on the FMLA, visit
www.dol.gov/esa/whd/fmla/index.htm. In addition, some states and local jurisdictions provide
broader family medical leave coverage to employees, so you should consult an attorney regarding
applicable state and local laws. If your Practice is required to comply with the FMLA, you may
consider requiring employees to exhaust their accrued paid leave at the same time they are on
FMLA leave. Otherwise, an employee could take up to 12 weeks of FMLA leave in addition to all of
his/her accrued vacation and sick leave.
Employers should consult state and local laws regarding family, medical, pregnancy or disability
leave that may provide more extensive coverage than the federal FMLA.
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COMPENSATION POLICIES
PAY PERIODS
The pay period will be for two (2) weeks or ten (10) working days:

The pay period will begin on Monday.

The pay period will end on the Friday of the second week.
Employees must report their hours to the practice manager on the Friday prior to the beginning
of the new pay period.
RECORDING OF TIME

The work week will be a standard forty-hour (40) week, running from Monday through
Friday each week.

Two (2) work weeks will equal one (1) pay period.

Employees will record their total hours for each week.

All vacation, sick, personal time, and other absent time will be recorded on the time card.
Employees will be paid only for time actually worked. If you work less than forty (40) hours per
week, you will be paid only for those hours, unless using time-off benefits (i.e., sick, vacation, or
personal time).
Paychecks include salary or wages earned less any mandatory or elected deductions.
Mandatory deductions include federal or state withholding tax, and other withholdings. Elected
deductions are deductions authorized by the employee, and may include, for example,
contributions to benefit plans.
Paychecks are issued biweekly. Employees will receive their paychecks on the Friday following
the reporting of their hours. If the pay date coincides with a holiday, paychecks will be
distributed on the closest business day before the holiday.
Notify a supervisor if your paycheck appears to be inaccurate or if it has been misplaced. The
Practice reserves the right to charge a replacement fee for any lost paychecks. Advances on
paychecks [are/are not] permitted. Information regarding final paychecks can be found under
the termination section of this handbook.
Any changes in name, address, telephone number, marital status, or number of exemptions
claimed by an employee must be reported to [person’s name] immediately.
The Practice should consult state and local law for wage payment requirements, such as means of
payment (including opportunity to pay by direct deposit), timeframe for paying wages, and
information that must be included on paycheck stubs.
OVERTIME PAY
The Practice assigns positions, determines wages, and compensates employees for overtime in
accordance with state and local laws and the Fair Labor Standards Act (FLSA). There are two
basic classifications of employees for purposes of overtime: exempt and non-exempt.
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Exempt: Professional, executive, and administrative personnel are considered to be exempt
from overtime and are paid a specified salary for all hours worked. These employees are
expected to work beyond their normal work hours whenever necessary to accomplish the work
of the Practice.
These include but are not limited to:

Licensed physicians.

Registered care administrators/managers who spend at least sixty (60) percent
of their time managing and directing the work of others.

Registered nurses.

Nationally certified and state licensed physician assistants who have at least
three (3) years of formal college-level training.
Non-Exempt: All other employees are non-exempt and qualify for overtime pay.
All overtime work by a non-exempt employee must be approved in advance by an employee’s
supervisor. Because unauthorized overtime is against Practice policy, employees who work
unauthorized overtime are subject to discipline, possibly including termination.
Non-exempt employees shall record all time worked, including time worked over their normal
schedule, on the time card at the time it actually occurs. Time is rounded to the next highest
quarter of an hour.
Overtime pay is calculated at one and one-half (1½) times the employee’s regular hourly rate of
pay for all hours over forty (40) hours in one work week. Overtime is computed on the basis of a
non-exempt employee’s total hours worked in a work week.
Hours that are paid for but not worked, e.g., holidays, sick days, and vacation days, do not
count as hours worked for overtime purposes.
Employers should consult state and local laws regarding overtime provisions that may be more
expansive than federal law, including, for example, requiring overtime after eight hours per day. In
addition, some jurisdictions have laws limiting overtime for health care professionals.
DOUBLE-TIME
Overtime hours in excess of twelve (12) hours in one workday are paid at double-time.
WEEKENDS
Weekend work does not automatically qualify for compensation at a premium rate of pay. Hours
worked on Saturdays and/or Sundays qualify for premium pay only if they qualify as overtime
hours under the standards noted above.
HOLIDAYS WORKED
Non-exempt employees who work on a Practice-recognized holiday shall be paid their straighttime rate of pay for hours actually worked on the holiday, plus the regular holiday pay for the
day.
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STANDARDS OF CONDUCT
EXPECTATIONS
The Practice expects every employee to act in a professional manner. Satisfactory performance
of job duties and responsibilities is key to this expectation. Employees should attempt to achieve
their job objectives and act with diligence and consideration at all times. Poor job performance
can result in disciplinary action, up to and including termination.
PERFORMANCE EVALUATION
Periodic performance evaluations provide a systematic and regular opportunity for the employee
and supervisor to discuss the employee’s work performance and establish goals for the future.
Regular performance evaluations are scheduled after ninety (90) days of employment, after
twelve (12) months of employment, and annually thereafter.
Employees should note that a performance review does not guarantee a pay increase or
promotion. Moreover, performance evaluations may be made at any time to advise employees
of unacceptable performance. Evaluations or any subsequent change in employment status,
position or pay does not alter the employee’s at-will relationship with the Practice.
GROUNDS FOR DISCIPLINARY ACTION
At-will employees can be terminated with or without cause. The Practice reserves the right to
discipline and/or terminate employees who violate its polices, practices or rules of conduct. The
Practice can also discipline employees, up to and including immediate termination, for poor
performance and/or misconduct.
The following actions are unacceptable and considered grounds for disciplinary action. This list
is not comprehensive; rather, it provides example of the types of conduct that this Practice does
not tolerate. These actions include, but are not limited to:

Engaging in acts of discrimination, harassment or retaliation in the workplace;

Possessing, distributing or being under the influence of illegal controlled substances;

Being under the influence of a controlled substance or alcohol at work, on Practice
premises, or while engaged in Practice business;

Unauthorized use or taking of Practice property;

Damage, destruction or theft of Practice property;

Removing Practice property without prior authorization or disseminating Practice
information without authorization;

Falsification, misrepresentation or omission of information, documents or records;

Lying;

Insubordination or refusal to comply with directives;

Failing to adequately perform job responsibilities;
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
Excessive or unexcused absenteeism or tardiness;

Disclosing confidential or proprietary Practice or patient information without permission;

Illegal or violent activity;

Falsifying injury reports or reasons for leave;

Possessing unauthorized weapons on the premises;

Disregarding safety and security procedures;

Disparaging or disrespecting supervisors and/or co-workers;

Insubordination; and

Any other action or conduct that is inconsistent with the Practice’s policies, procedures,
standards or expectations.
This list enumerates the types of actions or events that are subject to disciplinary action. It is not
intended to indicate every act that could lead to disciplinary action. The Practice reserves the
right to determine the severity and extent of any disciplinary action based on the circumstances
of each case.
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TERMINATION
Employment with the Practice is on an at-will basis and may be terminated voluntarily or
involuntarily at any time.
If an employee decides to terminate his or her employment, at least two (2) weeks advance
notification must be given in writing to his or her immediate supervisor and practice manager.
Vacation, sick, or personal time cannot be used as notice time.
Upon termination, an employee is required:

to continue to work until the last scheduled day of employment;

to turn in all reports and paperwork required to be completed by the employee when due
and no later than the last day of work;

to return all files, documents, equipment, keys, access cards, software or other property
belonging to the Practice that are in the employee’s possession, custody or control, and
turn in all passwords to his/her supervisor; and

to participate in an exit interview as requested by [enter authorized person’s name].
COBRA CONTINUATION OF HEALTH BENEFITS
Under the federal Consolidated Omnibus Budget Reconciliation Act (COBRA), a qualified
employee who terminates employment (for reasons other than gross misconduct on the part of
the employee) or who loses health and dental coverage due to a reduction in work hours may
temporarily continue group health and dental coverage for him/herself, his/her spouse, and any
covered dependent children at the full premium rate plus administrative fees. That eligibility
normally extends for a period of eighteen (18) months from the qualifying date. For more
information regarding COBRA health insurance benefits, see [enter name].
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DRUG/ALCOHOL ABUSE
The purpose of this policy is to emphasize the Practice’s prohibitions against on-the-job use or
possession of alcohol or illegal drugs; to make employees and supervisors aware of the
penalties for substance abuse; to improve the health of employees; to protect the safety of the
public and other employees; and to improve the quality of our products and services.
GUIDELINES
1. All employees are forbidden to use or possess alcohol or illegal drugs at any time during
the workday or anywhere on the Practice’s premises. Workers also are forbidden to
engage in any sale or other transaction involving illegal drugs. Violators will be subject to
immediate dismissal. Additionally, employees who are under the influence of alcohol or
drugs on the job will be subject to discipline.
2. The Practice has the right to search lockers, handbags, lunch boxes, other containers, or
other personal effects of workers at any time.
3. Employees who appear to be in an impaired condition on the job may be asked by their
supervisor to submit to a test to determine whether they are under the influence of
alcohol or illegal drugs. In addition, employees may be asked to submit to a test as part
of a general physical examination applicable to all employees. The types of tests that
may be used include breathalyzer tests, blood tests and urinalysis. Refusal to take any
such test will result in immediate dismissal. Employees who show a positive test result
may be required to undergo counseling, attend a rehabilitation program, and/or they may
be terminated.
4. Any sale of illegal drugs during the workday or on the Practice’s premises will be treated
as gross misconduct punishable by immediate discharge. Any employee who is arrested
for selling drugs while off duty will be discharged if convicted of a criminal offense.
5. All employees who must use a prescription drug that causes adverse side effects (e.g.,
drowsiness or impaired reflexes or reaction time) should inform their supervisor that they
are taking such medication on the advice of a physician. Such employees are
responsible for informing their supervisor of the possible effects of the drug on
performance and the expected duration of use. If the prescription drug use could cause
production or safety problems, a supervisor may grant the employee sick leave or
temporarily assign the worker different duties.
The legal risks and restrictions associated with drug and alcohol screening vary and can be complex.
Thus, the Practice should consult a local attorney who understands state or local restrictions on
employers. Specific procedures should be established and distributed to employees. The Practice
should contract with an accredited lab that follows appropriate procedures for collecting specimen and
validating results. It is essential that the Practice be very careful to keep test results confidential as
required by the Americans with Disabilities Act (ADA). The anti-discrimination provisions of the ADA
apply to employers with fifteen (15) or more employees. Employees who currently abuse alcohol, as
well as employees who formerly abused illegal drugs, can be considered “disabled” under the ADA
depending on the circumstances, thereby requiring the employer to reasonably accommodate the
employee as long as this does not create an undue hardship for the employer.
In short, there are many federal, state, and local laws that should be considered when drafting a drug
policy. It is advisable to have a local attorney review this policy to ensure that it conforms to state and
local law.
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ORGANIZATIONAL CHART
MEDICAL DIRECTOR
PRACTICE MANAGER
FRONT OFFICE
BACK OFFICE
BUSINESS OFFICE
Supervisor
Clinical Supervisor
Billing Supervisor
Patient Check-In
Technician
Billing/AR Clerk
Patient Check-Out
Scribe
Insurance Clerk
Receptionist
Clinic Assistant
Bookkeeper
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