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. c o m FLORIDA DEPARTMENT OF LAW ENFORCEMENT NOTICE FOR APPLICANTS SUBMITTING FINGERPRINTS WHERE criminal RECORD RESULTS WILL BECOME PART OF THE CARE PROVIDER background SCREENING CLEARINGHOUSE NOTICE OF: SHARING OF criminal HISTORY RECORD INFORMATION WITH SPECIFIED AGENCIES, RETENTION OF FINGERPRINTS, PRIVACY POLICY , AND RIGHT TO CHALLENGE AN INCORRECT criminal HISTORY RECORD This notice is to inform you that when you submit a set of fingerprints to the Florida Department of Law Enforcement (FDLE) for the purpose of conducting a search for any Florida and national criminal histor

florida department of law enforcement notice for applicants submitting fingerprints where criminal record results will become part of thecare provider background screening

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