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Sample Employee Discharge Form

September 15, 2022

Documenting what property/information of the practice/business has been given to the employees is very important. A log of all information/property that is provided to the employee, including a log of all software that can be accessed by the employee will save you many compliance and possible privacy breaches later. Simply refer to the log of documents/information/software access and fill out the following form at the termination of employment. Save this form in the employee’s folder for compliance.

Disclaimer: This document is only intended for educational purposes and does not contain legal advice.  by downloading this document, you will not establish any attorney-client relationship with Perla or its affiliates and agree to waive any liabilities or damages arising from the download or the use of this form. You must discuss any employment issues with a qualified employment lawyer who is familiar with healthcare employment issues. To find an employment healthcare attorney, you may search Perla’s network of healthcare advisors by clicking below.

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Reza Ghafoorian, MD, JD

Perla, Inc.

Perla is the first B2B matching service that connects healthcare businesses and healthcare professionals to vetted, trusted advisors and consultants with experience in the healthcare industry. At Perla, we screen advisors using a multistep process that checks licensing, insurance, client reviews, registrations, and more.

Employee Discharge Form

Employee Name:  __________________


The following documents, materials and devices were returned by the Employee upon termination of the Employment Agreement:

____ Documents: ______________________________________

____ Computer devices: __________________________________

____ Keys (including fobs): _______________________________ 

____ Passwords terminated: _______________________________

Signature of Manager___________________________

Sample Employee Discharge Form

Use this Form to document what property/information of the practice/business has been given to and returned by the employees.

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