Which lists must I check?

At minimum, query OIG LEIE, SAM, OFAC, and applicable state Medicaid or debarment lists. Healthcare providers should confirm payer-specific requirements; contractors should confirm contract clauses requiring additional lists.

How often should I rescreen staff?

Frequency depends on program risk: high-risk billers may justify monthly screening; many organizations use quarterly or annual rechecks. Document the policy and apply it consistently to show due diligence.

What to do if a probable match appears?

Immediately suspend billable activities for the individual if required by payer rules, escalate to compliance, perform manual adjudication using supporting IDs, and document the decision and rationale.

Are electronic consents and records valid?

Yes. Electronic consents and records are enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention requirements are satisfied.

How long must I keep screening records?

Retain records for the employment/contract term plus minimum federal baselines: typically 3 years (IRS IRC §6501(a)) and 6 years for certain healthcare records (45 CFR §164.530(j)). Check state variations.

Who should sign screening consent?

The subject of the check must provide written or electronic consent; include a dated signature or e-signature and record the method to demonstrate lawful authorization for the background check.

Electronic Signature
Templates
HR
Employee Exclusion List Check

Employee Exclusion List Check

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Employee Exclusion List Check

Personal Information

Full Legal Name Current Address

Phone Number

Email Address

Date of Birth Last Four Digits of SSN (for identity verification)

Position Information

Position Applied For / Current Position

Department

Reporting Manager

Anticipated Start Date

Salary / Hourly Rate

Employment History (Most Recent 2 Employers)

Employer 1 — Company Name Title / Position

Start Date

End Date

Primary Responsibilities Reason for Leaving

Employer 2 — Company Name Title / Position

Start Date

End Date

Primary Responsibilities Reason for Leaving

Education

Highest Degree or Certification Institution Name Graduation Date

References (Professional)

Reference 1 — Name Phone Email Relationship

Reference 2 — Name Phone Email Relationship

Reference 3 — Name Phone Email Relationship

Legal Disclosures and Policies

At-Will Employment: Employment with the organization is at-will. Either you or the employer may terminate the employment relationship at any time, with or without cause or notice, unless otherwise agreed in a separate written agreement signed by an authorized representative of the employer.

Equal Opportunity: The employer provides equal employment opportunity without regard to race, color, religion, sex, national origin, age, disability, genetic information, or any other characteristic protected by applicable law.

Acknowledgement of Policies

I acknowledge the At-Will Employment statement above. I acknowledge the Equal Opportunity statement above.

Exclusion List Screening Authorization and Disclosure

Purpose: The employer requires screening against exclusion, sanction, and debarment lists to ensure compliance with payer, contractual and regulatory obligations. By signing below you authorize the employer to query applicable exclusion and sanction lists using the personal information you have provided.

Type of Lists to be Checked (select all that apply)

Federal exclusion and sanction lists State exclusion and debarment lists Medicare/Medicaid and payer exclusion lists Other sanction or debarment lists as required by contract

Disclosure: Have you ever been listed on any exclusion, debarment, sanction, or similar list, or been subject to disciplinary action that resulted in an exclusion or revocation of license?

Yes — I have been listed or sanctioned No — I have not been listed or sanctioned

If yes, provide full details including dates, list name(s), and current status

Applicant Authorization: I authorize the employer to conduct exclusion and sanction screenings and to obtain any information necessary to verify my eligibility for employment. I understand that a confirmed record on an exclusion list may be grounds for refusal to hire or for immediate termination of employment. I also agree to notify the employer immediately if I am placed on any exclusion or sanction list during the course of my employment.

Consent to Background and Reference Checks

By checking the box below I expressly authorize the employer and its agents to contact prior employers and references and to obtain background, licensing, disciplinary, and exclusion information as required for employment eligibility and continued employment.

I authorize background, licensing, reference, and exclusion checks as described above.

Applicant Certification

I certify that all information supplied on this form is true, complete, and correct to the best of my knowledge. I understand that any false statements, omissions, or misrepresentations may disqualify me from employment or may be grounds for disciplinary action, including termination. I release former employers and listed references from liability for providing information in good faith.

For Human Resources Use Only

HR Verification: Complete the fields below after performing exclusion/sanction searches and reference checks.

HR Verifier Name

Date of Check

Method of Search

Search Outcome

No record found on checked lists Record found — see details

If record found, provide details and recommended action

Applicant Name:

Signature:

Date:

What the Employee Exclusion List Check Is and why it matters

An Employee Exclusion List Check is a documented screening process that compares an individual's identity details against federal and state exclusion, debarment, and sanction lists to confirm eligibility for employment or contract work. Typical sources include the OIG List of Excluded Individuals and Entities (LEIE), the System for Award Management (SAM) debarment list, state Medicaid exclusion lists, and Office of Foreign Assets Control (OFAC) sanctions. Organizations that bill federal health programs, hold federal contracts, or receive federal funds use this check to prevent payment to excluded persons and to reduce legal and financial exposure.

Why perform an Employee Exclusion List Check

Regular checks reduce risk of prohibited payments under federal programs, support compliance with program integrity rules, and document due diligence for audits and contracting requirements.

Who typically completes these checks

Several roles are responsible for initiating and documenting exclusion screening depending on organizational structure and program risk.

HR and recruiting teams run pre-hire and periodic screens for new hires and contractors.
Compliance and legal departments oversee policy, adjudication of matches, and record retention.
Contract and program managers screen subcontractors and contractors paid with federal funds.

Clear role assignment, documented procedures, and audit logs help demonstrate consistent compliance across hires and vendors.

Core components of a professional Employee Exclusion List Check

A complete check combines reliable data sources, consistent identifiers, documented frequency, and an auditable workflow for review and remediation.

Data Sources

Include OIG LEIE, SAM, state Medicaid exclusion lists, OFAC, and industry-specific debarment lists to ensure comprehensive coverage.

Identifiers

Collect full legal name, date of birth, and at least one unique ID (SSN/TIN or license number) to reduce false positives.

Screening Frequency

Define pre-hire and ongoing re-screen intervals (monthly, quarterly, or annually) based on program risk and contract terms.

Verification Method

Use exact-match and fuzzy-match logic, then manual adjudication for likely matches to confirm true exclusions.

Documentation

Record search queries, results, adjudication notes, reviewer identity, and dates to create an audit-ready trail.

Escalation

Specify steps for confirmed matches: suspend billable activities, notify legal, and follow program-specific reporting rules.

Required information and standard fields

Full legal name: First, middle, last

Date of birth: MM/DD/YYYY

SSN or TIN: Full or last 4 digits

State license: License number, state

Position/role: Job title or function

Employer ID: Internal identifier

Step-by-step: complete an Employee Exclusion List Check

Follow a four-step workflow to collect, screen, review, and record results in an auditable format.

01

Prepare data: Collect full name, DOB, SSN/TIN, license numbers.
02

Run searches: Query OIG LEIE, SAM, state lists, and OFAC.
03

Adjudicate matches: Manually review likely matches and document findings.
04

Record outcome: Save evidence, reviewer name, and date for audit trail.

Configure an online screening workflow

Typical configuration settings let you automate searches, choose authentication, and set retention and notification rules.

Field	Configuration
Authentication Method	Email link, SMS OTP, or SSO for reviewer access
Automatic Sources	Enable OIG LEIE, SAM, OFAC, and state feeds
Batch Processing	Support bulk uploads for contractor lists
Notifications	Auto-alert compliance on probable matches

Where to file and how to route completed checks

Define a clear routing path for results so HR, compliance, and contract managers receive the information they need.

Submit to HR: Attach result to the employee file in HRIS.
Share with Compliance: Send probable matches to compliance for adjudication.
Attach to Contract: Link contractor checks to contract records and POs.
Archive: Store completed checks in secure, access-controlled archive.

Delivery methods and technical requirements

Use secure, auditable distribution channels that preserve data protections and create an unalterable audit trail.

Integrations: Connectors to HRIS, EHR, or procurement systems (Salesforce, NetSuite, Google Workspace).
File formats: Use PDF or DOCX for static records; exports should include an audit log.
Access controls: Enforce role-based access and multi-factor authentication for reviewers.

Preserve chain-of-custody: signed acknowledgements, reviewer identities, and time-stamped audit trails help demonstrate consistent compliance during audits and contracting reviews.

Recommended screening cadence and timing expectations

Screening frequency should reflect program risk, contract terms, and payer expectations; document the schedule in policy.

Pre-hire screening:

Run before the employee begins billable or sensitive duties.

Initial contractor check:

Complete prior to first invoice submission.

Ongoing re-screening:

Monthly or quarterly for high-risk roles; annually for lower-risk.

Immediate response:

Investigate and suspend covered activities upon a confirmed match.

Audit readiness:

Maintain evidence and adjudication notes for regulator review.

Key milestones in the screening lifecycle

Track four numbered milestones from intake through archival to maintain control and evidence.

01

Intake and consent

Collect identifiers and signed consent from the subject prior to screening.

02

Automated search

Run queries against federal, state, and sanctions lists using configured sources.

03

Adjudication and decision

Compliance reviews probable matches and documents determinations and actions taken.

04

Archival and retention

Store final results, reviewer identity, and supporting documentation per retention policy.

Common errors to avoid

Incomplete identifiers (missing DOB or SSN) increase false positives and slow adjudication.
Relying on a single source (e.g., OIG only) misses state and OFAC exclusions.
Failure to document adjudication decisions undermines auditability and may trigger regulatory scrutiny.
No follow-up process for confirmed matches can lead to improper payments or contract violations.

Consequences of failing to screen or act on matches

Medicare exclusion: 42 U.S.C. §1320a–7

Debarment risk: SAM debarment affects federal contracting

Civil penalties: False Claims Act exposure possible

Payment ineligibility: Loss of federal program payments

Contract breach: Violation of grant or contract terms

Reputational harm: Public trust and regulatory scrutiny

eSignature vendor comparison for completing exclusion checks

Compare common eSignature plans on price and capabilities relevant to secure, auditable screening workflows. signNow is listed first per table convention.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Verify	Verify	Verify	Verify
Bulk Send	Yes (bulk send available)	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year limit	Verify	Verify	Verify

FAQs and troubleshooting for Employee Exclusion List Checks

Answers to common questions about scope, legal issues, and next steps when matches occur.

Need help? Contact support

Which lists must I check?
At minimum, query OIG LEIE, SAM, OFAC, and applicable state Medicaid or debarment lists. Healthcare providers should confirm payer-specific requirements; contractors should confirm contract clauses requiring additional lists.
How often should I rescreen staff?
Frequency depends on program risk: high-risk billers may justify monthly screening; many organizations use quarterly or annual rechecks. Document the policy and apply it consistently to show due diligence.
What to do if a probable match appears?
Immediately suspend billable activities for the individual if required by payer rules, escalate to compliance, perform manual adjudication using supporting IDs, and document the decision and rationale.
Are electronic consents and records valid?
Yes. Electronic consents and records are enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention requirements are satisfied.
How long must I keep screening records?
Retain records for the employment/contract term plus minimum federal baselines: typically 3 years (IRS IRC §6501(a)) and 6 years for certain healthcare records (45 CFR §164.530(j)). Check state variations.
Who should sign screening consent?
The subject of the check must provide written or electronic consent; include a dated signature or e-signature and record the method to demonstrate lawful authorization for the background check.

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