Kansas State Board of Healing Arts
800 SW Jackson Lower Level, Suite A., Topeka, KS 66612
Phone: (785) 296-7413; Fax: (785) 296-0852; Email: KSBHA_Licensing@ks.gov
Revised 11/14/19
A criminal background check is required prior to issuance of licensure. Be aware that fingerprint processing
may delay your application. Please make it a priority to complete the fingerprint process.
Following is the Waiver Agreement and FBI Privacy Act Statement. Please complete, sign and date the top
portion of this form. At the time fingerprints are collected the fingerprinting agency must complete the
bottom portion. Mail the completed form and fingerprint card to the Board. Fingerprints will not be
submitted for processing without a completed and signed Waiver Agreement.
Fingerprinting should be conducted by a person who is appropriately trained to collect fingerprints. It is not
necessary that it be a law enforcement agency, however they must be authorized to do fingerprints. Please
visit https://www.nbinformation.com/locations/locationMap.php
for a listing of fingerprinting locations.
Fingerprints to be submitted for background checks must be recorded on the current version of the FBI’s
Applicant Fingerprint Card, FD Form 258. Some agencies offer electronic scanning (Livescan) please note
the fingerprints must be printed on the fingerprint card and submitted to the Board. Please check with the
fingerprinting agency to see if fingerprint cards are available or if a fee is required. To request a fingerprint
card be mailed to you please email KSBHA_Licensing@ks.gov
or call (785) 296-7413.
Complete the applicant section of the fingerprint card. Ensure the appropriate data fields are completed
prior to submission. Include name, aliases, complete mailing address, social security number, citizenship,
date of birth, and personal information (sex, race, height, weight, eyes, hair, place of birth). The spaces for
OCA, FBI and MNU numbers can be left blank. Cards with missing or incomplete information will be
rejected and must be resubmitted.
Mail the completed Waiver Agreement and fingerprint card to the Board. You may want to use a mailing
service that allows for delivery confirmation.
Kansas State Board of Healing Arts
Attn: Licensing
800 SW Jackson, Lower Level – Suite A
Topeka, KS 66612
Phone: (785) 296-0934
Email: KSBHA_Licensing@ks.gov
Fingerprint results are valid for 6 months from the date received. Applications for licensure completed after
the 6-month period will be required to submit a new Waiver Agreement, fingerprint card, and $47 fee
Revised 08/2019 Page | 1
Fingerprint-Based Record Checks for Noncriminal Justice Purposes
I hereby authorize the Kansas State Board of Healing Arts to submit a set of my fingerprints to the Kansas Bureau of
Investigation (KBI) for the purpose of identifying me and accessing and reviewing Kansas and/or national criminal history
records that may pertain to me. Pursuant to K.S.A. 22-4701 et seq. and K.S.A. 22-5001, the Authorized Recipient may
obtain my criminal history record information for noncriminal justice purposes. By signing this waiver, it is my intent to
authorize release to the above-referenced Authorized Recipient of any Kansas and/or national criminal history record that
may pertain to me. I further understand that, if applicable, the Authorized Recipient may choose to deny me unsupervised
access to children, the elderly, or individuals with disabilities until the criminal history background check is completed.
I understand that, upon my request, the Authorized Recipient will provide me a copy of the criminal history background
report, received on me, for the purpose to challenge the accuracy and completeness of any information contained in any such
report. I may be afforded a reasonable amount of time to correct or complete the criminal history record (or decline to do so)
before the Authorized Recipient makes a final decision about my status as an employee, volunteer or contractor, or my
eligibility for any pertinent license, certification or registration, or adoption. See 28 CFR 50.12(b).
I understand that officials receiving the results of the criminal history record check are to use those results only for authorized
purposes and are prohibited from retaining or disseminating such results in violation of federal statute, regulation or
executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council.
(See 5 United States Code (USC) 552a(b); 28 USC 534(b); 42 USC 14616, Article IV(c); 28 CFR 20.21(c), 20.33(d), and
The FBI's acquisition, preservation, and exchange of information requested by this form is generally authorized under 28
U.S.C.534. Depending on the nature of your application, supplemental authorities include numerous Federal statutes,
hundreds of State statutes pursuant to Pub.L. 92-544, Presidential executive orders, regulations and/or orders of the Attorney
General of the United States, or other authorized authorities. Examples include, but are not limited to: 5 U.S.C. 9101; Pub.L.
94-29; Pub.L. 101-604; and Executive Orders 10450 and 12968. Providing the requested information is voluntary; however,
failure to furnish the information may affect timely completion or approval of your application.
Social Security Account Number (SSAN).
Your SSAN is needed to keep records accurate because other people may have the same name and birth date. Pursuant to the
Federal Privacy Act of 1974 (5 USC 552a), the requesting agency is responsible for informing you whether disclosure is
mandatory or voluntary, by what statutory or other authority your SSAN is solicited, and what uses will be made of it.
Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.
Principal Purpose:
Certain determinations, such as employment, security, licensing, and adoption, may be predicated on fingerprint-based
checks. Your fingerprints and other information contained on (and along with) this form may be submitted to the requesting
agency, the agency conducting the application investigation, and/or FBI for the purpose of comparing the submitted
information to available records in order to identify other
information that may be pertinent to the application. During the processing of this application, and for as
long hereafter as may be relevant to the activity for which this application is being submitted, the FBI
may disclose any potentially pertinent information to the requesting agency and/or to the agency conducting the
investigation. The FBI may also retain the submitted information in the FBI's permanent collection of fingerprints and related
information, where it will be subject to comparisons against other submissions received by the FBI. Depending on the nature
of your application, the requesting agency and/or the agency conducting the application investigation may also retain the
fingerprints and other submitted information for other authorized purposes of such agency(ies).
Revised 08/2019 Page | 2
Fingerprint-Based Record Checks for Noncriminal Justice Purposes
Routine Uses:
The fingerprints and information reported on this form may be disclosed pursuant to your consent, and may also be disclosed
by the FBI without your consent as permitted by the Federal Privacy Act of 1974 (5 USC 552a(b)) and all applicable routine
uses as may be published at any time in the Federal Register, including the routine uses for the FBI Fingerprint Identification
Records System
(Justice/FBI-009) and the FBI's Blanket Routine Uses (Justice/FBI-BRU). Routine uses include, but are not limited to,
disclosures to: appropriate governmental authorities responsible for civil or criminal law enforcement, counterintelligence,
national security or public safety matters to which the information may be relevant; to State and local governmental agencies
and nongovernmental entities for application processing as authorized by Federal and State legislation, executive order, or
regulation, including employment, security, licensing, and adoption checks; and as otherwise authorized by law, treaty,
executive order, regulation, or other lawful authority. If other agencies are involved in processing this application, they may
have additional routine uses.
Additional Information:
The requesting agency and/or the agency conducting the application-investigation will provide you additional information
pertinent to the specific circumstances of this application, which may include identification of other authorities, purposes,
uses, and consequences of not providing requested information. In addition, any such agency in the Federal Executive Branch
has also published notice in the Federal Register describing any system(s) of records in which that agency may also maintain
your records, including the authorities, purposes, and routine uses for the system(s).
You may request a copy of your state and/or national criminal history record from the Authorized Recipient for the purpose
of challenging for accuracy and completeness.
Alternatively, you may obtain a copy of your Kansas criminal history record information (CHRI) to review for accuracy
and completeness, by submitting a set of your fingerprints, a letter requesting your criminal history record, and payment of
the appropriate fee to the KBI. For further details, including the current fee, visit the following Internet website:
then find the brochure named “Record Checks for Non-Criminal
Justice Purposes”. Or, to provide official court documents to make a correction you may write to:
Kansas Bureau of Investigation
Attn: Criminal History Records
1620 SW Tyler
Topeka, Kansas 66612-1837
If a change is made to your Kansas criminal history record due to a challenge, a new copy of your Kansas criminal history
record will be sent to the Authorized Recipient to make a final decision about your status as an employee, volunteer or
contractor, or your eligibility for any pertinent license, certification or registration, or adoption.
To obtain a copy of your national CHRI, also known as the Identity History Summary, for review and challenge you
must submit a set of your fingerprints and the appropriate fee to the FBI. Information regarding this process may be obtained
at: https://www.fbi.gov/services/cjis/identity-history-summary-checks
. Or, you may write to:
FBI CJIS Division
Attn: Criminal History Analysis Team 1
1000 Custer Hollow Road
Clarksburg, West Virginia 26306
Revised 08/2019 Page | 3
Fingerprint-Based Record Checks for Noncriminal Justice Purposes
The FBI will forward your challenge to the appropriate contributing agency to verify or correct the entry. Upon receipt of an
official communication directly from that agency, the FBI will make any necessary changes/corrections to your record in
accordance with the information supplied by that agency (see 28 CFR 16.30 through 16.34). The Authorized Recipient must
submit a new set of fingerprints and fee to receive the updated federal criminal history record.
I have ____ OR have not ____ been convicted of a crime.
If convicted, describe the crime(s), the date and location of the crime(s), and the name of the convicting court:
Under penalty of perjury, I hereby declare that I am the person described below and understand that any falsification of this
statement constitutes a severity level 9, nonperson felony under the provisions of Title 21 Kansas Statutes Annotated, Section
The name, address, and date of birth provided below appear on a valid identification document as defined in Title 28 United
States Code, section 1028.
I have been provided the Waiver Agreement, FBI Privacy Act Statement, and information how to challenge my criminal
records for accuracy and completeness.
Signature Date
Printed Name Date of Birth
Residential Address City State Zip
Method of Verifying Identity: Driver’s License State Issued ID Card
Military ID Card
State/Branch: _______________________ ID Number: ____________________________________
Agency Name: _____________________________________________________________________________
Address: ____________________________________________________________________________________
Telephone: ______________________ Fax: ________________________
Name of Individual Verifying Identity: ____________________________________________________________
AUTHORIZED RECIPIENT: 1. Must maintain original or arrange for KBI to maintain.
2. Must provide a copy to the applicant.