Fillable 10-2850c - Application For Associated Health Occupations (Page 4 of 4) in pdf

AUTHORIZATION FOR RELEASE OF INFORMATION

In order for the Department of Veterans Affairs (VA) to assess and verify my educational background, professional qualifications and suitability for

employment, I:

Authorize VA to make inquiries concerning such information about me to my previous employer(s), current employer, educational institutions, State

Medical Boards, other professional organizations and/or persons, agencies, organizations or institutions listed by me as references, and to State

licensing boards, professional liability insurance carriers, national practitioner data bank, American Medical Association, Federation of any other

appropriate sources to whom VA may be referred by those contacted or deemed appropriate;

Authorize release of such information and copies of related records and/or documents to VA officials;

Release from liability all those who provide information to VA in good faith and without malice in response to such inquiries; and

Authorize VA to disclose to such persons, employers, institutions, boards or agencies identifying and other information about me to enable VA to

make such inquiries.

SIGNATURE

DATE

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICE

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of

section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information

unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 30 minutes. This

includes the time it will take to read instructions, gather the necessary facts and fill out the form.

AUTHORITY: The information requested on the attached application form and Authorization for Release of Information is solicited under Title 38, United

States Code, Chapters 73 and 74.

PURPOSES AND USES: The information requested on the application is collected primarily to determine your qualifications and suitability for

employment. If you are employed by the VA, the information will be used to make pay and benefit determinations and, as necessary, in personnel

administration processes carried out in accordance with established regulations and the published notice of the system of records "Applicants for

Employment under Title 38, U.S.C.-VA" (02VA135)

ROUTINE USES: Information on the form or the form itself may be released without your prior consent outside the VA to another Federal, State or local

agency, to the National Practitioner Data Bank which is administered by the Department of Health and Human Services, to State licensing boards, and/or

appropriate professional organizations or agencies to assist the VA in determining your suitability for hiring and for employment, to periodically verify,

evaluate and update your clinical privileges and licensure status, to report apparent or potential violations of law, to provide statistical data upon proper

request, or to provide information to a Congressional office in response to an inquiry made at your request. Such information may also be released without

your prior consent to Federal agencies, State licensing boards, or similar boards or entities, in connection with the VA's reporting of information concerning

your separation or resignation as a professional staff member under circumstances which raise serious concerns about your professional competence.

Information concerning payments related to malpractice claims and adverse actions which affect clinical privileges also may be released to State licensing

boards and the National Practitioner Data Bank. The information you supply may be verified through a computer matching program at any time.

EFFECTS OF NON-DISCLOSURE: See statement below concerning disclosure of your social security number. Disclosure of the other information is

voluntary; however, failure to provide this information may delay or make impossible the proper application of Civil Service rules and regulations and VA

personnel policies and thus may prevent you from obtaining employment, employees benefits, or other entitlements.

INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PUBLIC LAW 93-579 SECTION 7(b)

Disclosure of your SSN (social security number) is mandatory to obtain the employment and related benefits that you are seeking. Solicitation of the SSN is

authorized under the provisions of Executive Order 9397, dated November 22, 1943. The SSN is used as an identifier throughout your Federal career from

the time of application through retirement. It will be used primarily to identify your records. The SSN also will be used by Federal agencies in connection

with lawful requests for information about you from your former employers, educational institutions, and financial or other organizations. The information

gathered through the use of the number will be used only as necessary in personnel administration processes carried out in accordance with established

regulations and published notices of systems of records. The SSN also will be used for the selection of persons to be included in statistical studies of

personnel management matters. The use of the SSN is made necessary because of the large number of present and former Federal employees and applicants

who have identical names and birth dates, and whose identities can only be distinguished by the SSN.

VA FORM

10-2850c

PAGE 4

NOV 2016 (R)