Get Authorized Person Designation Form Justice Center Staff Exclusion ...

Completing the Authorized Person Designation Form is essential for ensuring that the designated individual can request checks on the Staff Exclusion List. This guide provides clear, step-by-step instructions to help users fill out the form efficiently and accurately online.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Part 1 of the form, enter the first name, last name, middle initial, email address, and business phone number of the Authorized Person. Ensure that all information is complete and accurate.
3. Next, fill out the full provider name, avoiding any abbreviations. Complete the business address fields, including state, city, and zip code. Each field must be completed to ensure the form is valid.
4. Read the statement regarding the responsibilities and confidentiality requirements carefully. By signing, the Authorized Person agrees to comply with these responsibilities. After reviewing, enter the date and sign in the designated area.
5. Proceed to Part 2, where the Director of the Provider Agency must sign to approve the designation. The Director should fill out their name, title, and date, before signing the form.
6. In Part 3, complete the necessary agency information, including the relevant codes for the oversight agency your provider belongs to. Ensure that all information is correct and complete.
7. Once all parts of the form are completed, save your changes. You can download, print, or share the form as needed. Ensure that it is returned to the Justice Center via email or fax.

Get started on completing your documents online today!