GATEWAY HEALTH INC. NOTICE/DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION
This authorization and consent for release of personal information acknowledges that Gateway Health Hospice (hereinafter referred to as
“GATEWAY HEALTH HOSPICE”) may conduct investigations. These investigations may include, but are not limited to: searches of
financial or credit agencies, investigation of personal history, records of previous employment (including detailed information on work
history), searches of educational institutions, military records, criminal history information on file in local, state or federal agencies, workers
compensation records, and motor vehicle/driver’s license records.
I understand that these searches will be used to determine employment eligibility under the GATEWAY HEALTH HOSPICE’s employment
policies. Therefore, I authorize and consent for full release of records (either orally or in writing) to the authorized representative of
GATEWAY HEALTH HOSPICE. In addition, I release and discharge GATEWAY HEALTH HOSPICE and its agents and associates to the
full extent permitted by law from any claims, damages, losses, liabilities, costs, expenses, or any other charge or complaint filed with any
agency arising from retrieving and reporting this information. I understand that this notice will apply to any future update reports that may be
requested and is valid for up to one year from the date below for hiring purposes. After reading this document, I understand fully its
complete contents and I authorize the background verification.
In the event that information from the report is utilized in whole or in part in making an adverse decision with regard to your potential
employment, we will provide you with a copy of the consumer report and a description in writing of your rights under the Federal Fair Credit
NOTICE: You have the right to request disclosure of the nature and scope of our investigation and/or a
written summary of your rights under section 609(c) of the federal Fair Credit Reporting Act by providing
us with a written request within a reasonable time of our background investigation.