Policy Manual sample

MDT Home Health Care Agency, Inc. CONSENT FORM TO RELEASE PHYSICAL-MEDICAL EXAMINATION CRIMINAL BACKGROUND SCREENING DATA FORM I have been formally instructed that my Physical Examination Form, and any medical and/or Criminal Background screening data is to be kept confidential and understand that the medical information regarding my health status may not be discussed with anyone, either inside or outside the agency (except as needed to conduct the business of the day). I understand that no medical/criminal data is to be removed from the home health agency unless a "Release of Information" form has been completed and signed by me. It is my understanding that such Release of Information (THIS FORM), authorizes the Agency to release my Physical/Background Information data to State/Federal surveyors at their request if needed to conduct the annual survey or any necessary investigation. I have been formally instructed in the Personnel Policies and Regulations, and I have read and signed a job description for my specific classification. ________________________________ __________________ Employee Name Date ________________________________ Signature Home Health Agency. - - Personnel/Operations Policies B-69