Attachment 6 - DHHS Interpreter Release of Information.pdf

Release of Information

I, as a prospective provider of services understand the need for and give permission to Nebraska Department of Health and Human Services and/or Contractor to have my name checked through Law Enforcement Agencies concerning contacts, citations, arrests, and through the Nebraska State Central Registries of Adult and Child Abuse/Neglect, and the Nebraska State Patrol’s Sex Offenders Registry.

The following information is required for positive identification as the screening checks are conducted.

Full Legal Name: ____________________________________________________________________________________________

All former names – maiden/other married/nick names: _____________________________________________________________

SS#: _________________________________ Date of Birth: __________________________________________

Home Address: ______________________________________________________________________________________________ (Address/city/state/zip) Phone: ______________________________ Cell: __________________________________________

List Addresses where you have lived in the last 2 years: Towns, Counties, and States where you have resided and dates you lived there:

Have you ever been convicted of any infraction, misdemeanor or felony? Yes No Explain:____________________________________________________________________________________________________

I understand that the information received will be utilized by Nebraska Department of Health & Human Services in making decisions regarding approval of a contract to provide translation or interpreter services. I also understand that completion of this form does not guarantee that DHHS will request interpreter services, make a referral or authorization for payment.

Signature: ________________________________________ Date: _______________________________

For Office Use:

SOR:

NDEN:

CPS:

DMV:

APS:

OTHER: