PRIVACY POLICY ACKNOWLEDGEMENT FORM - …

RICK SCOTT GOVERNOR Better Health care for all Fl oridians ELIZABETH DUDEK SECRETARY PRIVACY POLICY ACKNOWLEDGEMENT FORM I acknowledge that I have received a copy of the PRIVACY polici es fr om the florida Department of Law Enforce ment and the Federal Bureau of Investigation, which describe the exchange of information where criminal record results will become part of the care Provider Background Scr eening Clearinghouse. I underst and and agree that I will read and co mply with the guidelines contained in the PRIVACY policies. Employee/Contractor Name (Printed) Employee/Contractor Signature Date 272 7 M a h a n D r i v e , M S # 4 0 T a l l a has s ee, F l o r i d a 3 2 3 0 8 V i s i t A H C A onl i n e a t A H C A . M y F l o r i da.

RICK SCOTT GOVERNOR Better Health Care for all Floridians ELIZABETH DUDEK SECRETARY PRIVACY POLICY ACKNOWLEDGEMENT FORM I acknowledge that I have received a copy of the privacy policies from the Florida Department of

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