AmanaCare Background Check Authorization

First Name *

Last Name *

Email *

Street Address *

City *

State *

Zip code *

Three Professional References *

Date of birth *

Driver's License Number *

Social Security Number *

Photo of Driver's License *

Upload a Photo of Your Driver's License

Photo of Social Security Card *

Upload a Photo of Your Social Security Card or Birth Certificate

Criminal Background Check Authorization

Name *

I understand that AmanaCare, LLC requires the following background information on me. A History may be requested from law enforcement or criminal justice agencies including but not limited to: E-Verify for employment eligibility, State of Nebraska Adult/child abuse neglect registry, Law Enforcement records (i.e. Nebraska State Patrol), State of Nebraska Sex Offenders Registry, GSA website for debarment actions by federal agencies and exclusion actions from Medicare, Medicaid, and other federal programs through the office of inspector general at https://exclusions.oig.hhs.gov/, System for Award Management https://usfcr.com/search-sam-cage-duns/ , Nebraska Department of Motor Vehicles Nebraska driver license information system, NE sanctioned provider information https://dhhs.ne.gov/Pages/Program-Integrity-Sanctioned-Providers.aspx

Have you ever been arrested or charged with a criminal offense? *

If "Yes," please explain.

Signature *

Clear

Today's Date *

Criminal Background Check Release of Information Authorization Form

Name *

I understand that the State of Nebraska Bureau of Investigation, Division of Criminal Information and its official and employees shall not be held legally accountable in any way for providing this information to the above named healthcare provider, and I hereby release said HHA and persons from any and all liability which may be incurred as a result of furnishing such information. I further understand that the healthcare provider cannot provide me with a copy of the results of this criminal history record check.

Signature *

Clear

Today's Date *