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Attachment E <br />PERMISSION FORM TO OBTAIN <br />BCRC DRUG STATUS <br />BYBCRC ID NUMBER OR SOCIAL SECURITY NUMBER <br />Before an employee's BCRC status can be released to an employer verbally by <br />BCRC, the employee must first sign for the release of his/her status by the use <br />of his/her BCRC I.D. Number or Social Security Number. <br />Per BCRC Policy Revision January 1, 2020, Page 36, Card System &Status <br />Confirmation Article: <br />The card manager shall maintain the strictest confidentiality of the BCRC membership. <br />The Employer is required to <br />obtain appropriate written consent from its <br />Employees to access any information about such Employees from the BCRC <br />database, and is required to comply with all provisions of the BCRC Policy <br />regarding access to such information. Such access can be obtained by having <br />their card status verged on their job site in order to determine if the Employee <br />is available or not available under the BCRC program. <br />I , give my permission for the following company to obtain <br />(please print your full name) <br />the information of my availability status from BCRC by using my BCRC I.D. <br />Number or my Social Security Number. <br />Company Name: <br />Company Card Manager Name: <br />Card Manager Contact Phone Number: <br />Site Location: <br />Employee/Member Name: <br />Employee/Member BCRC I.D. #: <br />Driver's License #: <br />State of Issue: <br />Or Employee/Member Social Security Number: - <br />Employee/Member Signature Date <br />Please fax form back to BCRC at (219) 764-9505 <br />"PHIS FORM IS CONFIDENTIAL AND MUST BE HELD INA SECURED LOCATION AT ALLTIMES' <br />