RICCOBENE ASSOCIATES

RICCOBENE ASSOCIATES FAMILY DENTISTRY

Thank you for working at Riccobene Associates Family Dentistry! Please complete the basic questions below so we can add you to our HR/Payroll system.
NEW HIRE FORM - W2 employee (payroll/HR)

Please complete this form to ensure we add you to our HR/payroll system [Paycom]. You will be receiving an email directly from Paycom with your employee self-service login and password. Please complete the 'new hire checklist' to ensure you get paid properly. In the checklist you will need to complete tax forms, direct deposit forms, form I9, etc. You will also complete online training on how to enter time, enroll in benefits, etc. Please allot 10-15 minutes to complete. In addition, you will be able to go under 'time management' and submit your hours directly.
Please keep an eye out for your employee self-service login from PAYCOM to complete 'NEW HIRE CHECKLIST' which MUST be completed before payroll is processed. Please also bring copy of 2 forms of identification for employment verification (ex: driver's license and social security card OR passport).

Welcome aboard! If you have any questions please email hr@brushandfloss.com
Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Hire Date/Date started working *

Month Day Year
Date
Date of Birth *

Month Day Year
Date
Social Security # (XXX-XX-XXXX) *
Gender *
Position *
Position title (if applicable)
Office Location (which office are you working in?) *
How did you hear about us?
Name to appear on Name Badge *
example: John Doe, Dental Hygienist or John M. Doe, Dental Hygienist
Signature *

If Dentist please complete section below:

If you are a dentist, hygienist, these are items that are needed prior to you working for compliance purposes.
NC Dental License #
Provide copy of NC Dental license (you can take copy from smart phone and upload below):

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NPI #
DEA # (if applicable)
Provide copy of Individual malpractice insurance (you can take copy from smart phone and upload below):

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Please provide CAQH username/user ID [needed for credentialing purposes, may need to get from previous employer]
Please upload copy of resume in preparation of credentialing paperwork

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If Dental Hygienist please complete section below:

If you are a temp dentist, temp hygienist, these are items that are needed prior to you working for compliance purposes.
Dental Hygienist License #
Please upload Dental Hygienist License (upload from smart phone)

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Cancel of

If Dental Assistant please complete section below:

If you are a temp dentist, temp hygienist, these are items that are needed prior to you working for compliance purposes.
Did you graduate from an accredited Dental Assistant Program (ex: Wake Tech, etc.- this is where your diploma includes your X-ray, coronal polishing certifications & you are a DA2)
If 'yes'....Please provide copy of diploma from accredited DA program (you can use smart phone to upload picture)

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If 'no'....please provide copy of x-ray certification

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If 'no'....please provide copy of coronal polishing certification (if applicable)

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Cancel of
If 'no'....please provide copy of nitrous certification (if applicable)

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Thank you for submitting! Your information has been submitted to the HR department.

Please keep an eye out for your employee self-service login from PAYCOM to complete 'NEW HIRE CHECKLIST' which MUST be completed before payroll is processed. Please also bring copy of 2 forms of identification for employment verification (ex: driver's license and social security card OR passport).

Welcome aboard! If you have any questions please email hr@brushandfloss.com
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RICCOBENE ASSOCIATES FAMILY DENTISTRY

NEW HIRE FORM - W2 employee (payroll/HR)

If Dentist please complete section below:

If Dental Hygienist please complete section below:

If Dental Assistant please complete section below: