EMPLOYEE AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION ON EMPLOYMENT FILE, BACKGROUND CHECK, FINGERPRINTING, MEDICAL RECORDS, RANDOM DRUG SCREENING, KNOWLEDGEABLE OR CONFIDENTIAL INFORMATION ABOUT CANDIDATE /EMPLOYEE, AND CLIENT, PATIENT, EMPLOYER CONFIDENTIALITY STATEMENT.
By affixing my signature hereunder, I authorize Texas Nurse Connection, Ltd to release any and all confidential employment, background check and medical information contained in my employment file to any medical facility or entity with whom Texas Nurse Connection, Ltd has a staffing agreement, and to any other governmental or regulatory agency at such agency’s request. For all other purposes, Texas Nurse Connection, Ltd shall keep my employment records confidential and shall advise any medical facility or other entity to whom records have been provided to also keep such records confidential. I hereby waive any privilege I may have to this information with respect to its release to Texas Nurse Connection, Ltd.
Regarding the MEDICAL RECORDS, BACKGROUND CHECKS AND FINGERPRINTING RELEASE, this internal information is confidential, and we will instruct our client facilities or other entities to treat the information provided confidentially as well.
Regarding the DRUG SCREENING RELEASE, I voluntarily consent to a urine, blood or breathe sample for the purposes of an alcohol, drug, intoxicant, or substance abuse screening test. Furthermore, I voluntarily consent to the release of the test results to Texas Nurse Connection, Ltd, or its designee, for purposes of determining the fitness for employment or continued employment.
I voluntarily consent, that all KNOWLEDGEABLE OR CONFIDENTIAL INFORMATION ABOUT CANDIDATE/EMPLOYEE history may be disclosed to Client/Facility.
Regarding the CLIENT, PATIENT, AND EMPLOYER’S CONFIDENTIALITY STATEMENT, I voluntarily consent that all information will be kept in strict confidence and will not be shared with any individual outside of those working for Texas Nurse Connection, Ltd. Confidential information is the property of clients, patients, or Texas Nurse Connection, Ltd.
My signature hereunder further indicates that I have read the EMPLOYEE AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION ON EMPLOYMENT FILE, BACKGROUND CHECK, FINGERPRINTING, MEDICAL RECORDS, RANDOM DRUG SCREENING, KNOWLEDGABLE OR CONFIDENTIAL INFORMATION ABOUT CANDIDATE/EMPLOYEE AND CLIENT, PATIENT, AND EMPLOYER CONFIDENTIALITY STATEMENT in its entirety and understand its contents.
I certify that the facts contained in this application are true and accurate. I understand that any misrepresentation or omission of facts is cause for dismissal. As a condition of employment, I understand and agree to submit to a drug screening and background investigation, and if accepted for employment, shall and do hereby consent to random drug or screening if assigned to work in a patient care position. I authorize the employer to investigate any and all statements contained herein and request the persons, firms, and/or corporations named above to answer any and all questions relating to this application. I release all parties from all liability the employer and any person, firm or corporation who provides information concerning my prior education, employment or character.
Texas Nurse Connection, Ltd does not discriminate in respect to hiring, firing, compensation, and all other terms and conditions of privileges of employment on the basis of race, color, national origin, ancestry, sex, age, pregnancy, or related medical conditions, marital status, religious creed, physical handicap not related to the ability to do the job, or a medical condition related to cancer or age.