Request Employment Verification

PICS, as the employer of record, verifies employment and other confidential information to third parties as requested by our Workers. HIPAA and State guidelines direct the rules and regulations of sharing individual's information. PICS requires written consent from each individual detailing what information we may release and to whom.

This form must be completed and submitted before PICS will share your information with a third party.

Please allow 48 hours for processing.

First Name

Last Name

Phone Number

Date of Birth

I authorize Partners in Community Supports to release information to the following individual or organization:

Individual or Organization Name

Fax Number

Address

City/Town

State/Province

ZIP/Postal Code

I authorize Partners in Community Supports to release information to the following individual or organization (check all that apply)

Date of Hire

Day of Employment Termination

Pay Rate Information

Earnings

Medical and Dental Benefits Eligibility

Other

By clicking "I Agree," I release any individual, including records custodians, from all liability for damages that may result to me on account of compliance or any attempts to comply with this authorization. This release is binding, now and in the future, on my heirs, spouse, assigns, associates, and personal representative(s) of any nature. Copies of this authorization that show my release request are as valid as the original request that I'm sending directly to Partners In Community Supports.

I agree