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Please complete a separate Participation Agreement for each facility/provider location.
Must be President, Vice President, CEO or other Officer Authorized to Execute on Behalf of and Bind the Entity to a Contract.

 The DCH Voluntary Background Check Program for Health Care Facilities or Providers was established in 2015 by the DCH Health Care Facility Regulation Division and the DCH Office of the Inspector General.  Participation in the program is not required; however, nursing homes are required to complete State background checks of certain employees pursuant to O.C.G.A. § 31-7-350,  may fulfill this requirement through voluntary participation in this program.  More information on the program is available at www.dch.ga.gov