BACKGROUND CHECK FORM

It requires that a health facility/agency that is a: psychiatric facility hospital that provides swing bed services ICF/MR home for the aged nursing home home health agency county medical care facility hospice shall not employ, independently contract with, or grant clinical privileges to an individual who regularly has direct access to or provides direct services to patients or residents in the health facility/agency until the health facility or agency conducts a fingerprint-based criminal history check.

An individual who applies for employment either as an employee or as an independent contractor or for clinical privileges with a health care facility/agency and has received a good faith offer of employment, an independent contract, or clinical privileges shall give written consent at the time of application for the care facility/agency to conduct a criminal history check, and shall give a written statement disclosing that he or she has not been convicted of a crime that would prohibit employment.

NOTE: Throughout this form "employee" includes persons independently contracted with and/or those granted clinical privileges.

Name*

A health facility or agency, including a psychiatric facility, a hospital that provides swing-bed services, an intermediate care facility for individuals with intellectual disabilities (ICF/IID), a home for the aged, a nursing home, a home health agency, a county medical care facility, or a hospice, shall not employ, independently contract with, or grant clinical privileges to an individual who regularly has direct access to or provides direct services to patients or residents until the facility or agency has conducted a fingerprint-based criminal history check.

An individual who applies for employment, either as an employee or independent contractor, or who applies for clinical privileges with a health facility or agency and has received a good-faith offer of employment, an independent contract, or clinical privileges, must provide written consent for the facility or agency to conduct a criminal history check. The individual must also submit a written statement affirming that he or she has not been convicted of a crime that would prohibit employment, contracting, or the granting of clinical privileges under applicable law.

As a condition of being considered for employment:

a. I hereby consent to and authorize the health facility/agency to conduct a background check, including a search of state and federal abuse and neglect registries and databases, as well as a fingerprint-based search of state and federal criminal history records. I understand that this consent includes the release and sharing of such information with the State Departments of Community Health, Human Services, Corrections, and State Police.

b. I hereby authorize the release of any relevant information to the health facility/agency for use in conducting the background check as required under applicable state House Bill rules.

c. I understand that, except in cases involving the knowing or intentional release of false information, the health facility/agency has no liability in connection with a background check conducted under applicable state House Bill rules or the release of criminal history record information for the purpose of making an employment decision.

d. I understand that the health facility/agency will make the final employment determination. I also understand that the health facility/agency may terminate the background check process or decide not to hire me at any stage of the process.

e. I understand that, if the health facility/agency denies employment based on reasonable reliance on information obtained through a background check, the health facility/agency is immune from any action brought by me as the applicant due to the employment decision.

The following convictions and/or findings may disqualify you from working in long-term care facility/agency: a. Relevant Crime Described under 42 USC 1320a-7 - 42 USC 1320a-7 is a statutory provision within the Federal Social Security Act which describes a number of crimes for which a conviction will exclude an individual from participation in any federal health care program. The crimes include patient abuse, health care fraud, as well as any crimes.

 

NOTE: Throughout this form "employee" includes persons independently contracted with and/or those granted clinical privileges.

I agree to provide the information necessary to conduct a criminal background check. I understand that, upon my request, the health facility/agency will provide me with a copy of any disqualifying record information identified through any relevant registry, database, or background check.

I understand that, if I believe any disqualifying information obtained from a relevant registry or database is inaccurate, it is my responsibility to contact the agency that maintains the registry or database and pursue correction of the information.

I understand that, if I believe the results of the fingerprint-based criminal history record check are inaccurate, or if the criminal conviction contained in the record may be eligible for expungement or to be set aside, I may file an appeal with the ACHA in accordance with applicable laws, regulations, and procedures.