Sample Disclosure and Authorization Form and FCRA Summary of Rights
Non Emergency Medical Transportation Clients
**PLEASE NOTE THAT THIS IS A SAMPLE SET OF DOCUMENTS. IT IS BEING PROVIDED TO YOU SOLELY AS A COURTESY. IT SHOULD NOT BE CONSTRUED AS LEGAL ADVICE. USE OF SAMPLE DOCUMENTS PROVIDED BY OCCUSCREEN, LLC IS ENTIRELY OPTIONAL. THEREFORE, IF YOU CHOOSE TO USE OCCUSCREEN, LLC’S SAMPLE DOCUMENTS IN PART OR WHOLE, YOU UNDERSTAND AND AGREE THAT SUCH DOCUMENTS SHALL BE CONSIDERED YOUR OWN (NOT THAT OF OCCUSCREEN, LLC). PLEASE CONSULT WITH COUNSEL AS APPROPRIATE TO CONFIRM THAT YOUR DOCUMENTS COMPLY WITH ALL APPLICABLE FEDERAL, STATE, AND LOCAL LAWS.
Disclosure Form Usage Requirement:
Consent for employment screening is required by the FCRA prior to screening services being initiated on any applicant/employee.
As a reminder, please be sure to add your company name to the documents in the spaces provided. Our contact information as the Consumer Reporting Agency is already included, as required when using our services.
Specific Jurisdiction Notices:
Below are samples of jurisdiction-specific forms to be included with the Disclosure and Authorization form if you, or your applicant, are located in these areas. This is not an all-inclusive list, and you should be sure to check with your counsel to confirm what is needed in your location.
- District of Columbia Notice of the Right to File a Complaint
- City of Los Angeles Fair Chance Initiative
- NY Article 23-A
- New York City Notice of Rights
- Philadelphia Fair Chance Hiring Law
- San Francisco Fair Chance Ordinance
If you have questions about this information, please reach out to us at firstname.lastname@example.org.