Provider Handbook Acknowledgment Form

I acknowledge that I have received a copy of Management Registry, Inc. Provider Handbook. I acknowledge that I have been informed that the complete Management Registry, Inc. employee handbook is available www.managementregistry.com.

I understand that in processing my application with Management Registry, Inc. an investigation may be made in which information is obtained through personal interviews, and a review of information held by law enforcement or other government agencies. I authorize you to verify my past employment and education, criminal records, motor vehicle records, personal references, and other job related data provided on this application, or via the interview process. I authorize appropriate individuals, companies, institutions or agencies to release information, and I release them from any liability as a result of such inquires or disclosures. A consumer report may be generated summarizing this information. I further understand and waive my right of privacy in this investigation and release and hold harmless Management Registry, Inc. from any liability. I agree that any decision to hire me is contingent upon the results of my report and certify that all statements and answers on my application, resume, or interview are true and complete to the best of my knowledge. I understand that if any statements are false or that if information has been omitted, this will be cause for disqualification and immediate termination of my employment. If employed, I further authorize Management Registry, Inc. to check my credit and conviction records, as needed, on a continuous basis as it relates to my employment. I am granting Management Registry, Inc. authorization to release confidential medical information upon the request from Management Registry, Inc. clients while I am actively working at the client’s facility and /or during the profiling and placement processes.

I understand that Management Registry, Inc. goal is to always provide me with a consistent level of service.  If for any reason I am dissatisfied with Management Registry, Inc. or the service provided by one of Management Registry, Inc. Clients, I am encouraged to contact the local manager to discuss the issue.  Management Registry, Inc. has processes in place to resolve customer complaints in an effective and efficient manner.  If the resolution does not meet my expectation, I am encouraged to call the Management Registry, Inc. corporate office at (888) 851-3588.  A corporate representative will work with me to resolve my concern.  I understand that any individual or organization that has a concern about the quality and safety of patient care delivered by Management Registry, Inc. healthcare professionals, which has not been addressed by Management Registry, Inc. management, is encouraged to contact the Joint Commission at www.jointcommission.org or by calling the Office of Quality Monitoring at (630) 792-5636.  Management Registry, Inc. demonstrates this commitment by taking no retaliatory or disciplinary action against employees when they do report safety or quality of care concerns to the Joint Commission.