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Home
About Us
Services
Chronic & Specialized Care
Adult & Child Disability Care
Cancer Care
Diabetes & Dialysis Care
Memory Care (Alzheimer’s & Dementia)
Parkinsons Care
Stroke Recovery Care
Post-Surgical & Mobility Recovery
Orthopedic & Surgical Recovery
Hospice & Palliative Care
Essential Home Care
Child Care Services
Respite Care
24/7 Home Care
Companion & Travel Assistance
Areas We Service
Pricing
Careers
Blog
Contact Us
561-678-0111
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Attestation of Compliance with Background Screening Requirements
Employee/Contractor Name
Health Care Provider/ Employer Name
Address of Health Care Provider
Consent
I have been granted an Exemption from Disqualification through the Agency for Healthcare Administration (AHCA).
Date of Decision
MM slash DD slash YYYY
Consent
I have been granted an Exemption from Disqualification through the Florida Department of Health.
Date of Decision
MM slash DD slash YYYY
**A copy of the Exemption from Disqualification decision letter must be attached**
If you are also using this form to provide evidence of prior Level 2 screening (fingerprinting) in the last 5 years and have not been unemployed for more than 90 days, please provide the following information. A copy of the prior screening results must be attached.
Purpose of Prior Screening
Date of Prior Screening
MM slash DD slash YYYY
Screening conducted by:
Agency for Healthcare Administration
Department of Health
Agency for Persons with Disabilities
Department of Elder Affairs
Department of Financial Services
Department of Children and Family Services
Attestation
Under penalty of perjury, I,
hereby swear or affirm that I meet the requirements for qualifying for employment in regards to the background screening standards set forth in Chapter 435 and section 408.809, F.S. In addition, I agree to immediately inform my employer if arrested or convicted of any of the disqualifying offenses while employed by any health care provider licensed
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