To Whom It May Concern:

I, _________________________________, authorize the Health Care Authority to contact my current and/or previous employers and anyone else appropriate in establishing my qualifications for the purposes of verification and reference. I knowingly and voluntarily release the State of Washington Health Care Authority, its individual employees, and all my former or present employers and their individual employees, from any and all known and unknown claims for damages or other relief arising out of the department’s request for and receipt of employment information, unless my current or former employer is prohibited by state or federal law from disclosing the information that the department requests. This authorization includes review of state employee personnel files. Date___________________ Printed name of applicant_____________________________________

Applicant’s signature___________________________________

Where did you hear about this job? ______________________________________________________________

NOTE: A photocopy of this information shall be as valid as the original.