Consent form

ACKNOWLEDGEMENT OF APPLICANTS NON-CRIMINAL JUSTICE
PRIVACY RIGHTS AND CONSENT TO BE INCLUDED IN THE CAREGIVER PORTAL

SECTION I - PRIVACY RIGHTS - TO BE COMPLETED BY INDIVIDUAL BEING FINGERPRINTED

APPLICANT TYPE (Pick from the list) : *

FULL NAME (Required) :

Home Address (Street) :

Home Address (City) :

Home Address (State) :

Home Address (Zip):

Email Address (Required) : *

Telephone No (Required) : *

Name of Facility (Required) : *

Facility (Street) :

Facility (City) :

Facility (State) :

Facility (Zip):

I confirm authorization *

I hereby authorize the Georgia Department of Community Health (OCH), Office of Inspector General, to receive any criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency In Georgia. I understand a State and Federal fingerprint criminal background check will be conducted. By signing below, I am indicating that I have read and understand the terms and conditions of the attached Non-Criminal Justice Applicant's Privacy Rights and Policy Act Statements.

Date of authorization:

APPLICANT TYPE (Pick from the list) :

SECTION II- CAREGIVER PORTAL - TO BE COMPLETED ONLY BY AN APPLICANT OR EMPLOYEE BEING FINGERPRINTED AS PART OF FACILITY LICENSURE. DOES NOT INCLUDE OWNERS OR FAMILY EMPLOYERS.

The Georgia Caregiver Portal only contains the eligibility status of applicants and employees who have successfully passed the bad(ground screening process. The Caregiver Portal does not contain the names of applicants and employees who are ineligible. Family employers can access the Caregiver Portal to view a prospective applicant or current employee's eligibility to determine their suitability for employment to provide personal care services to that employer's elderly family member or wards. All services are performed at locations not licensed by OCH. Individuals should check one of the boxes below. *

I agree to the results of my background check determination being available to family employers in the Georgia Caregiver Portal.
I am seeking employment only by licensed healthcare employers. I do not want or agree to the results of my background check determination being available to family employers.

Date of Confirmation: *

(** Once Submitted, please make sure to return and complete the Application Form in the adjacent open Tab **)

Call now: +(770) 853-9558

Consent Form

ACKNOWLEDGEMENT OF APPLICANTS NON-CRIMINAL JUSTICE PRIVACY RIGHTS AND CONSENT TO BE INCLUDED IN THE CAREGIVER PORTAL

SECTION I - PRIVACY RIGHTS - TO BE COMPLETED BY INDIVIDUAL BEING FINGERPRINTED

ACKNOWLEDGEMENT OF APPLICANTS NON-CRIMINAL JUSTICE
PRIVACY RIGHTS AND CONSENT TO BE INCLUDED IN THE CAREGIVER PORTAL