Georgia Criminal History Check System (GCHEXS) Access Request Form

HFRD License Application Number

User Type

Director/Manager/Administrator

Owner

Full Name of User (required)

Phone Number of User (required)

Email Address of User (required)

Facility Name (required)

Facility/Provider Address (required)

No P.O. Boxes

City (required)

State (required)

Zip Code (required)

Facility/Provider License Number (If Applicable)

Upload contract

Upload a copy of the contract between the staffing agency and the long term care facility.

One file only.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

First Name of Owner/Administrator (required)

Last Name (required)

Phone Number of Facility (required)

Date of Signature (required)

Signature

By checking this box and typing my name above, I am electronically signing my name to receive a username and password to access GCHEXS. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.|

If you have any questions please email [email protected] or call 404-463-7154.

Georgia Criminal History Check System (GCHEXS) Access Request Form

Call Us

Visit

Hours