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Pre-Authorization of Clearance Letter Submission

This form should be used to submit a Notarized "Clearance Letter" issued by a Healthcare Entity Licensed by the Mississippi Department of Health to request clearance for an engagement at UMMC. Documents uploaded here will be reviewed by UMMC Human Resources. This form should be submitted by the person named below.

Examples of individuals who should use this form include affiliated students and individuals onboarding through the ENEPAR process, but may also include those engaging with UMMC in other capacities as well. If you are unsure if you should upload documents here, please contact Human Resources at hrservicecenter@umc.edu.

Please provide the following information in order to complete your upload:

Full Name* 
Other names used
Email* 
Type of engagement* 
Attachment* 
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf, *.gif,*.jpg,*.jpeg,*.bmp,*.png,*.tif,*.tiff
By submitting this form I attest that I am the person name above and that the attached document was issued to me by appropriate authority. I acknowledge my obligation to submit a Change of Legal Status Disclosure Form if I have had any changes to my legal status since the issuance of this letter and until the end of my engagement with UMMC. “Changes to legal status” may include, but are not limited to, charges resulting from arrests, criminal convictions of both misdemeanor and felony crimes, and changes to sex offender registry status.