Criminal Background Studies Employee List

CRIMINAL BACKGROUND STUDIES EMPLOYEE LIST

Client Name:

Employer:

Co-employer (if applicable)/If using Agency with Choice (typically managing party):

Names of all staff persons, paid or unpaid, on the plan who are required to have a background study because they work directly with the client.

NOTE: Persons on the plan that work for a company that we can reasonably believe have already passed a criminal background study completed by that company, are not required.

1. 11.

2. 12.

3. 13.

4. 14.

5. 15.

6. 16.

7. 17.

8. 18.

9. 19.

10. 20.

Case Manager Instructions: Must enter a separate line in SMARTS for criminal background study billing, if there is any direct care staff. SMARTS has appropriate codes/rate. Fill out number of studies needed during this plan date span.

CLS/DD – CDCS – DAK7172 (09/2012)