Where to send the application: The Agency reviews applications and makes decisions for Exemptions for:

Transcription

1 BACKGROUND SCREENING Applicatin fr Exemptin AUTHORITY: In accrdance with sectin , Flrida Statutes, persns disqualified frm emplyment may be granted an exemptin frm disqualificatin. The granting f an exemptin des nt change an individual s criminal histry. It nly prvides eligibility fr emplyment in a health care setting. An individual seeking an exemptin must demnstrate by clear and cnvincing evidence that an exemptin frm disqualificatin shuld be granted. The applicatin will be reviewed and a decisin made nce all relevant dcumentatin listed belw has been received. A persn is nt eligible t apply fr an Exemptin frm Disqualificatin until: He/she has been lawfully released frm cnfinement, supervisin, r ther nnmnetary cnditin impsed by the curt fr a disqualifying misdemeanr criminal ffense; At least 3 years after he/she has been lawfully released frm cnfinement, supervisin, r ther nnmnetary cnditin impsed by the curt fr a disqualifying felny criminal ffense. He/she has cmpleted any curt-rdered fee, fine, fund, lien, civil judgment, applicatin, csts f prsecutin, trust, r restitutin as part f the judgment and sentence fr any disqualifying felny r misdemeanr in full. Persns designated as sexual predatrs, sexual ffenders r career ffenders are nt eligible fr an Exemptin frm Disqualificatin. APPLICATION CHECKLIST: The fllwing items must be included with this Applicatin fr Exemptin frm Disqualificatin: A current Level II screening was cnducted electrnically thrugh the Agency fr Health Care Administratin r the Care Prvider Backgrund Screening Clearinghuse by an apprved live scan vendr. (Fr mre infrmatin regarding Level II backgrund screenings, please visit: Arrest reprts fr all ffenses listed n the criminal histry reprt. The arrest reprt is a detailed narrative that explains the reasn fr yur arrest. Arrest reprts may be btained frm the law enfrcement (plice department, sheriff s ffice, etc.) agency that made the arrest. Curt dispsitins fr all ffenses listed n the criminal histry reprt. Curt dispsitins may be btained frm the clerk f the curt in the cunty in which yu were arrested. The dispsitin is the curt dcument that states what yu were actually sentenced fr and the cnditins f yur sentence. Signed Statement (nly needed if yu cannt btain the arrest reprt and/r curt dispsitin): Please write a detailed statement n each arrest explaining why yu were arrested. Yu must include the victim s age and relatinship t yu and the sentence yu received (prbatin, jail, prisn, etc.). If yur ffense was related t theft, please include the item(s) and the apprximate value f the item(s) stlen. Dcumentatin frm the clerk f curt and/r the arresting agency must be prvided n letterhead indicating the dcument(s) are n lnger available. Please make sure yu sign the statement.* If yu were given prbatin r parle, yu will need a letter frm the prbatin department with the fllwing infrmatin required fr each ffense: the date yu started prbatin r parle; the date yu are scheduled t terminate prbatin r parle; if yu are eligible fr early terminatin f prbatin r parle; if yu have vilated prbatin r parle; and if s, what was the vilatin. Prvide 3-5 letters f reference. One reference letter must be frm a current r mst recent emplyer n the emplyer s letterhead. Other letters must be frm individuals yu have knwn fr at least tw years thrugh cntact at the wrkplace, cmmunity activities, educatin, r training centers. Individuals prviding a letter f recmmendatin shuld include their name, address, and telephne number fr verificatin r pssible interview. Dcumentatin f rehabilitatin. Rehabilitatin includes successful cmpletin f a curt-rdered treatment r cunseling prgram, educatinal, r training certificates, prf f participatin in cmmunity activities, special recgnitin, r awards received. Page 1 f 6

2 Where t send the applicatin: The Agency reviews applicatins and makes decisins fr Exemptins fr: Send yur applicatin t: - unlicensed persnnel wrking fr a health care prvider - facility wner, administratr, r chief financial fficer - Medicaid Prvider Enrllment - Medicaid Managed Care Health Plan Backgrund Screening Unit Agency fr Healthcare Administratin 2727 Mahan Drive MS #40 Tallahassee, FL (850) The Department f Health reviews applicatins and makes decisins fr licensed and certified health care prfessinals as lng as that persn is wrking in the scpe f his r her license r certificatin. Fr mre infrmatin regarding the exemptin prcess fr licensed r certified individuals with the Department f Health, visit r by calling Page 2 f 6

3 AHCA Use Only BACKGROUND SCREENING Applicatin fr Exemptin Date Received: Date 1 st Reviewed: Date Omissins Sent: Date Appl. Cmplete: Hearing? Y N Decisin Date: AUTHORITY: In accrdance with sectin , Flrida Statutes, this applicatin is submitted fr an Exemptin frm Disqualificatin t seek emplyment in a health care setting fr which emplyment was denied due t a disqualifying criminal histry ffense. Disclsure f yur scial security number is vluntary. The Agency fr Health Care Administratin shall use such infrmatin fr purpses f internal identificatin. NOTE: The granting f an exemptin by any State Department (including this Agency) des nt clear the criminal histry. The exemptin nly prvides eligibility fr emplyment despite the presence f a disqualifying ffense(s). The exemptin nly prvides eligibility fr emplyment despite the presence f a disqualifying ffense(s). If granted, an exemptin shall be vided if yu receive a new disqualifying criminal ffense after the date the exemptin is issued. 1. PERSONAL INFORMATION Please select any f the fllwing that apply: I applied fr emplyment with a health care prvider in a psitin that des nt require licensure r certificatin (i.e. Dietary, hmemaker r cmpanin sitter, hme health aide, etc.) and must btain an exemptin befre I can wrk. I am an wner, administratr r chief financial fficer fr a health care prvider that is currently licensed r seeking licensure by the Agency. I have submitted an applicatin fr enrllment as a Medicaid Prvider. I am emplyed with a Medicaid Managed Care Health Plan. Principals f the prvider entity include any fficer, directr, billing agent, managing emplyee, r affiliated persn, r any partner r sharehlder wh has an wnership interest equal t 5 percent r mre in the prvider. NOTE: If yu are seeking an exemptin t wrk as a CNA, RN, LPN r ther licensed r certified psitin, please cntact the apprpriate licensing bard at the Department f Health. Last Name: First Name: Middle Name: Maiden Name: Mailing Phne Number: Please include Area Cde City: State: Zip: Optinal Scial Security Number: Date f Birth: mm/dd/yyyy Sex: List All Prir Names, Aliases, AKAs: Race: White Black Indian Asian r Pacific Islander Other: (INDICATE HISPANIC AS BLACK OR WHITE BASED ON SKIN COLOR) Have yu applied fr an exemptin frm disqualificatin with anther state agency? YES NO If yes, cmplete the fllwing: State Agency where exemptin request was submitted: (i.e. Department f Children and Families, Department f Health, etc.) M F Date applicatin submitted: Exemptin decisin: Date f decisin: Granted Denied Withdrawn Still under review NOTE: Even if yu have received an exemptin frm disqualificatin frm anther state agency, yu are still required t apply fr an exemptin thrugh this Agency. Prf f exemptin must be prvided with the applicatin. The Agency will take int cnsideratin any exemptin that is granted thrugh anther state agency when making a decisin. Page 3 f 6

4 2. EMPLOYMENT INFORMATION Name f Prvider where yu are emplyed r seeking emplyment: Street Phne Number: Please include Area Cde City: State: Zip: Please select the type f health care prvider fr which yu wrk r were denied emplyment due t yur criminal histry: Adult Day Care Center Health Care Clinic ICF/DD Adult Family Care Hme Health Care Services Pl Nurse Registry Assisted Living Facility Hme Health Agency Nursing Hme Cmmunity Mental Health Hme Medical Equipment Prescribed Pediatric Extended Care Crisis Stabilizatin Unit Hmemaker/Cmpanin Service Residential Treatment Facility/Center Durable Medical Equipment Hspice Other: Please select the type f psitin yu are seeking an exemptin. NOTE: Nurses, Certified Nursing Assistants and ther prfessins licensed r certified thrugh the Department f Health (DOH) must apply fr an exemptin thrugh the apprpriate licensing bard at DOH. Administratr Chief Financial Officer/ Dietary Hme Health Aide Owner / Operatr w/ 5% r mre interest Mental Health Persnnel Risk Manager Hmemaker/Cmpanin Sitter Maintenance Nursing Assistant (nn-certified)/patient Aid Relief Persn Emplyee / Staff Persn Other: 3. EMPLOYMENT HISTORY Identify the name and address f each emplyer, supervisr, address, telephne number, dates f emplyment and yur jb respnsibilities fr the last 5 years. Please explain any breaks in emplyment that exceed 3 mnths. Attach additinal sheets if necessary. Current r Mst Recent Emplyer: Emplyer: Page 4 f 6

5 Emplyer: Emplyer: Emplyer: 4. EDUCATION / TRAINING Please cmplete the fllwing and include cpies f any certificates, diplmas, and licenses if applicable. 1. What is yur highest level educatin cmpleted? Did nt cmplete high schl AA Degree Dctrate GED r equivalent BS/BA degree Other: High Schl Diplma Master s Degree 2. Are yu enrlled in r have yu cmpleted a training prgram t btain certificatin r prfessinal licensure in a health-related ccupatin? Yes N If Yes, please cmplete the fllwing: Name f Schl/Prgram Type f Training (Hme Health Aide, Nursing Assistant, etc.) Date f Training Training Cmpleted? Certificate r License Received? Yes N Yes N Yes N Yes N Yes N Yes N Yes N Yes N Page 5 f 6

6 3. Are yu a licensed r certified health care prfessinal? Yes N If yes, please prvide yur license r certificate number: 4. Have yu registered fr examinatins required t btain certificatin r prfessinal licensure in a health related ccupatin? Yes N If yes, please cmplete the fllwing: Type f Exam Date Applied fr Exam Date f Exam 5. CONFIRMATION TO REQUEST AN EXEMPTION REVIEW By submitting this applicatin I frmally request an exemptin review in accrdance with sectin , Flrida Statutes. The infrmatin in this applicatin and the dcuments I have prvided are true and crrect. I understand that it is my respnsibility t prvide clear and cnvincing evidence that I will nt pse a danger t the health r safety f health care patients r their prperty. I als understand that the decisin f the Agency fr Health Care Administratin regarding this exemptin may be cntested thrugh a hearing requested under the prvisins f Chapter 120, Flrida Statutes. I understand that infrmatin and dcuments submitted in this applicatin are public recrds and shall be subject t public inspectin as prvided fr in Chapter 119, Flrida Statutes, except fr infrmatin exempted by law frm public viewing. * Pursuant t , F.S., whever knwingly makes a false statement in writing with the intent t mislead a public servant in the perfrmance f his r her fficial duty shall be guilty f a misdemeanr f the secnd degree, punishable as prvided in , F.S., r , F.S. Please Print Yur Name Signature Date Page 6 f 6