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Applicant Tracking Systems
From OIG/GSA Excluded Persons searches to FACIS searches, Info Cubic is your “one-stop shop” for healthcare background checks.
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Section A: Consumer Information
Please complete all sections and fields of this form. Per the Fair Credit Reporting Act (FCRA), reinvestigations can take up to 30 days to process. Note, completing this form is not mandatory. If you wish to submit a dispute via phone, please call 1-303-220-0169, or complete the form here.
Create User
Date Of Birth*
Do you have a Social Security Number? Last 4 digits*
YesNo
State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest-VirginiaWisconsinWyomingOthers
Section B: Disputed Information
Provide a description of the item(s) that you are disputing or the statement you would like included in the report. Be as specific as possible and include case numbers, charges and dates of the information you are disputing. If applicable: Please include supporting documentation (court documents, expungement papers etc.). Please email a copy to us and reference that the information is being provided as part of a dispute. (Email address will be provided on the final confirmation page)*
Please upload any available supporting document.
Section C: Disclosure Method
Info Cubic will provide the results of your reinvestigation request by mail, using the address provided on this request form. Sensitive information such as your date of birth and SSN are truncated on the report for security.
If you wish to receive the results of your request by another method please specify below.
Report Delivery Preference:*—Please choose an option—E-mailFaxMail
FAX:
*Using the email address or the mailing address provided in Section A of this reinvestigation request.
Section D: Authorization Release
Please complete the following release to authorize the reinvestigation request.
I, authorize the release of any information to Info Cubic and/or its agents, pertaining to my criminal, employment or address history for the purposes of the reinvestigation that I have requested. I also authorize you to notify the company that requested my report of my dispute and to provide them with the reinvestigation results. Further, I authorize you to provide updated reports to any other employers who may have received a consumer report with the disputed information over the last two years. I understand that the results of the reinvestigation will be mailed to me unless I have specified otherwise in Section C of this form. By signing and submitting this form I agree that I am the person named above and understand that federal law has specific consequences in place for individuals attempting to obtain information from a consumer reporting agency under false pretenses.
Date:* Please leave this field empty.
