TX HHS Form 8622. Consent for Criminal History Check

The TX HHS Form 8622, Consent for Criminal History Check, is a crucial document that helps ensure the integrity of the State Long-Term Care Ombudsman Program. This form is used in situations where representatives of the Office of the State Long-Term Care Ombudsman, including volunteers and staff, need to undergo a criminal history check to verify their eligibility for the program.

The form requires applicants to provide specific information, including their name(s) ever used, email address, phone number, and physical address. Additionally, applicants must disclose any prior convictions, pending legal charges, and current or previous related licenses or certifications. The form also emphasizes the importance of reporting criminal charges, indictments, or convictions immediately to the Ombudsman Program.

To complete this form, applicants must certify that the provided information is correct and provide their printed name, signature, and date. Local Ombudsman Entities are responsible for verifying the applicant's government-issued ID and retaining the original form at their office. The form can be submitted via email or fax to the Ombudsman Program Office Manager.

• This form is used by representatives of the State Long-Term Care Ombudsman Program, including volunteers and staff.
• The form requires applicants to provide specific information about their criminal history.
• Applicants must report any criminal charges, indictments, or convictions immediately to the Ombudsman Program.