002.03 PROVIDER RELEASE OF INFORMATION AND STATEMENT OF CRIMINAL HISTORY.

Individual providers must sign a release of information and statement, identifying any felony or misdemeanor convictions and pending criminal charges. This statement must include complete details, dates, and disposition. If the provider will be providing services in the provider’s home, the provider must also provide this information for all household members. Providing incomplete or inaccurate information may result in the provider being denied participation or terminated from the program.