Primary Care Advanced Practice Provider

In connection with my application for employment (including contracts for services), I understand and authorize Portage Path Behavioral Health to obtain a background report for employment purposes. I understand that this inquiry may include, but is not limited to: criminal records, motor vehicle records, credit records, address verification, social security verification, civil court records, bankruptcy records, personal or professional references, education verification, and copies of prior personnel files. An inquiry may be made as part of a pre-employment screening process.

I AUTHORIZE. WlTHOUT RESERVATION, ANY PART OR AGENCY CONTACTED ON BEHALF OF PORTAGE PATH BEHAVIORAL HEALTH TO FURNISH THE ABOVE-MENTIONED INFORMATION AND RELEASE THAT PARTY FROM ANY LIABILITY AND RESPONSIBILITY FOR DOING SO. A COPY OF THIS AUTHORIZATION SHALL HAVE THE SAME AUTHORITY AS THE ORIGINAL.

I hereby release and discharge Portage Path Behavioral Health and their employees, agents successors and assigns, from any and all liability that may arise out of the investigation of my background as set forth herein.

Use of date of birth is for identification purposes only and will be used only by the Consumer Reporting Agency to obtain background information about you. Consistent with its equal employment policies, Portage Path Behavioral Health will not consider this date of birth for the purposes of making any hiring decision.

This authorization and disclosure is pursuant to the Fair Credit Reporting Act, 15 U.S.C. §I681 b(b)(2)(B).

I agree that as a condition of applying for and, if offered, accepting employment at Portage Path Behavioral Health, I will be subject to the Company's policy regarding substance abuse. Specifically, as a condition for consideration of my application for employment, I agree to undergo testing for prohibited drugs and/or alcohol. I further understand and agree that if employed, as a condition of my employment, I will be required to submit to testing for drugs and/or alcohol under the following circumstances:

1. I am discovered using, possessing or distributing prohibited drugs or alcohol in violation of the Company's Substance Abuse Testing or Drug-Free Workplace Policy.
2. I am involved in an on-the-job accident that results in injury to me or any other individual which requires medical treatment, or which results in damage to Company property.
3. I commit an unsafe act that endangers the lives or safety of other employees, clients or other individuals or endangers Company property.
I understand that the purpose of the drug/alcohol testing is to determine or rule out the presence of prohibited substances in my body for performance and safety reasons. I understand that if employed, as a condition of employment, if I refuse to comply with the company substance abuse policy, I will face disciplinary action, up to and including termination.

Prohibited drugs are defined to include:
1. Controlled substances including, but not limited to: amphetamines, barbiturates, benzodiazepines, cannabinoids (marijuana), cocaine, phencyclidine (PCP), opiates; methaqualone.
2. Prescription drugs which have not been specifically prescribed by a licensed physician, prescribed for the employee, or are not being used for or in the manner prescribed.
3. Over-the-counter medications which are not being used for or in the manner recommended.
I understand that once I am an employee of Portage Path Behavioral Health and should the results of the initial drug/alcohol screening be positive, I may request that confirmatory testing be done by the Company's designated laboratory at my expense. If the confirmatory test is negative, the Company will reimburse me for the cost of the confirmatory test.

I understand that pursuant to Company policy, the Company may search me and my property if reasonable suspicion exists to believe that I have violated the Drug-Free Workplace or Substance Abuse Testing Policies. As a condition of employment, I consent to all such searches.

I consent to and authorize Portage Path Behavioral Health and any physician, laboratory, hospital or medical professional retained by Portage Path Behavioral Health to both conduct such testing and to provide the results to Portage Path Behavioral Health. I release Portage Path Behavioral Health, their employees, agents, contractors and successors and assigns from any liability whatsoever arising from the request to undergo drug/alcohol testing, the testing procedures and any decisions made concerning continued employment based upon the results of the tests conducted.

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

By typing my name on the Applicant Signature line below, I understand this electronic signature is the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.