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BACKGROUND & CREDIT CHECK DISCLOSURE AND AUTHORIZATION FORM
DISCLOSURE
This form, which you should read carefully, has been provided to you because a Tenet Healthcare facility (the “Company”)
may request consumer reports on you from a consumer reporting agency. The Company will use any such report(s) solely for
employment purposes, including those associated with contractors, students, volunteers, physicians and others performing
work for the Company.
Consumer reports on you will be obtained by the Company from HireRight, Inc., (“HireRight”) located at 2100 Main Street,
Suite 400, Irvine, CA 92614. They can be contacted at 1 800-400-2761. Information that may be obtained includes social
security number verification, criminal records, public court records, educational records, verification of volunteer and/or
employment positions held and verification of licensing and certifications. The information contained in these reports may be
obtained by HireRight from private and/or public record sources including sources identified by you in your job application.
A credit history will be procured only if the position you are applying for has fiduciary or cash handling
responsibility, you would be issued a corporate credit card once employed, or if you will be entering into a
relocation agreement.
A driving records check will be procured only if the position you are applying for requires a valid driver’s license.
With this Disclosure and Authorization form you are also being provided a copy of a “Summary of Your Rights Under the Fair
Credit Reporting Act” as issued by the Federal Trade Commission.
AUTHORIZATION
By signing your name below you :
Indicate you have carefully read and understand this Disclosure and Authorization form
Consent to the release of consumer reports to the Company in conjunction with your job application
Understand that if the Company hires you, your consent will apply throughout your employment unless you
revoke or cancel your consent in writing by sending a signed letter or statement to the company
Authorize the disclosure to HireRight of information concerning your employment history, earning history,
education, criminal history, credit history (when pertinent to the position being applied for) and motor vehicle
history (when pertinent to the position being applied for).
This Disclosure and Authorization form, in original, faxed, photocopied or electronic form, will be valid for any reports that
may be requested by the Company.
SIGNATURE: ________________________________ DATE: _____________________________
PRINTED NAME: ____________________________
For California Facilities and residents of California, Minnesota and Oklahoma: Please check the appropriate box below.
I would like a copy of the report. I waive my right to receive a copy of the report.
If you live or are applying for a job in the state of California, please review this additional notice: You may view the file
maintained on you by HireRight during normal business hours. You may also obtain a copy of this file, upon submitting
proper identification and paying the costs of duplication services, by appearing at HireRight’s offices in person, during normal
business hours and on reasonable notice, or by mail. You may also receive a summary of the file by telephone. HireRight has
trained personnel available to explain your file to you, including any coded information. If you appear in person, you may be
accompanied by one other person, provided that person furnishes proper identification.