AgencyForm - Background Check

Step 1: Agency Information

AUTHORIZED USE ONLY: Access to this system is restricted to authorized users for the sole purpose of conducting mandatory background checks as required by state and federal law. Unauthorized access or misuse of confidential information is strictly prohibited and subject to legal penalties. All activities are monitored.

Organization (Full Legal Name)*

Current PATH Provider ID (if applicable)

FEIN (Federal Employer Identification Number)*

Agency Type *

Contact Info:

Organization Contact Person*

Primary Contact Email Address *

Phone Number*

Extension

Step 2: Address Information

Current Physical Address *

Address Line 2 (Optional)

City *

State *

Zip Code *

County *

Mailing address same as Physical address

Current Mailing Address *

Address Line 2 (Optional)

City *

State *

Zip Code *

County *

Step 3: Acknowledgement and Agreement

This is an Authorization and Release for Protective Service Record Check for Provider and Agency Personnel. Please review the Acknowledgement and Agreement Statement before submission.

The information provided above is the required data for the registration of agencies seeking access to the WV VeriCheck background portal. I certify that the information provided above is true, accurate, and complete to the best of my knowledge, and I am authorized to register this organization with the State's background check system.

By checking this box, I acknowledge that I have read, understand, and agree to the above statement.

Contact Signature

Date

West Virginia DoHS Background Check Request

Step 1: Agency Information

Contact Info:

Step 2: Address Information

Step 3: Acknowledgement and Agreement