HR Third-Party Access Form

HR Third-Party Access Form

Personal Information

Position Information

Third-Party Designee

Scope of Access (select all that apply)

Payroll and wage information
Benefits enrollment and claim information
Leave of absence and leave records
Medical or health plan information (if applicable)
Personnel file, employment history, and disciplinary records
Performance reviews and manager notes
Authority to make changes to HR records (check only if authorized)
Other (describe):

Access Duration and Limits

Access shall commence on: and shall expire on: unless earlier revoked in writing by the employee.

If access is intended to remain in effect until revoked, check here:

Legal Authorization and Notices

By signing below, I authorize the employer's Human Resources and Payroll departments and their authorized employees or agents to disclose the records, information, and documents described above to the named designee to the extent permitted by law. This authorization includes verification of employment dates, salary, benefits enrollment, leave status, and other personnel records unless specifically limited above.

I understand that certain categories of information may be protected by law and may require additional consent prior to disclosure. I represent that I have the legal right to authorize disclosure of my records and I will provide further written authorization if required for release of health or other specially protected information.

The designee is required to present valid identification when requesting records. The employer is authorized but not required to provide copies of records. The employer is not responsible for any unauthorized re-disclosure by the designee. This authorization remains in effect only for the period specified above unless revoked earlier in writing.

Certifications and Acknowledgments

I certify that all information provided on this form is true and complete. I authorize the employer to verify any information provided herein, and to contact prior employers and other references for employment verification and background investigation as permitted by law. I understand that false statements or omissions may result in disciplinary action under company policy.

I understand that I may revoke this authorization at any time by delivering a signed written revocation to the Human Resources department. Revocation will be effective upon receipt, except where disclosures have already been made in reliance on this authorization.

I authorize Human Resources to contact previous employers, references, and third parties to verify the information provided and to conduct background checks to the extent permitted by applicable law.

Employment History

Provide at least two recent employers. Include company, job title, dates of employment, principal responsibilities, and reason for leaving.

Education

References (Professional)

Company Policies & Statements

At-Will Employment: Nothing in this form alters the at-will nature of employment. Employment may be terminated by either party at any time with or without cause or notice unless governed by a separate written agreement signed by authorized representatives.

Equal Employment Opportunity: The employer provides equal employment opportunity in accordance with applicable law. Decisions regarding employment, benefits, and access to records are made without unlawful discrimination.

Additional Employee Certification

I certify that I have read and understand the terms of this Third-Party Access Form. I authorize the employer to provide the scope of information requested to the designee listed above for the purposes stated. I acknowledge that I may revoke this authorization at any time in writing. I agree to indemnify and hold the employer harmless from any claim arising from disclosure of information in accordance with this authorization.

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