In making application for the granting or renewal of membership and clinical privileges (“clinical privileges” means permission from a healthcare organization to provide specific healthcare services to its patients, members, etc.) at Provider OnBoarding (hereinafter “Healthcare Organization”), I hereby consent during the evaluation process to the disclosure, inspection and copying of information and documents relating to my credentials and qualifications by and between the Healthcare Organization and other healthcare organizations and individuals with whom I have been associated or at which I have held membership or applied for clinical privileges. The purpose of this consent is to permit the evaluation of my application. This consent to access my information may include and extends to members of a hospital medical staff, medical groups, independent practice associations (IPAs), health plans, health maintenance organizations (HMOs), preferred provider organizations (PPOs), other healthcare delivery systems or entities, medical societies, professional associations, medical school faculty, training programs, professional liability insurance companies (with respect to certification of coverage and claims history), licensing authorities, and businesses and individuals acting as agents on behalf of such organizations. Information that may be relevant and subject to release is that information regarding my professional competence, training, experience, character, conduct and judgment, ethics and ability to work with others. I also understand that, in authorizing the release of such information, due care will be taken to safeguard the privacy of patients and the confidentiality of patient records.

To the fullest extent permitted by law, I hereby release all persons and entities, including this Healthcare Organization, its officers, employees and agents, engaged in quality assessment, peer review, credentialing and privileging, and all persons and entities providing information to representatives of the Healthcare Organization from any liability they might incur for their acts and/or communications in connection with evaluation of my qualifications for membership or clinical privileges in the Healthcare Organization.

I also agree that I will notify the Healthcare Organization in writing, within five (5) days of receiving any written notice of any adverse action, including, without limitation, any filed and served malpractice suit or arbitration action; the receipt of a Notice of Claim; any final adverse action taken or report made to the National Practitioner Data Bank as defined under the Healthcare Quality Improvement Act of 1986, any report made to the Healthcare Integrity and Protection Data Bank, any notice that I have been placed on the OIG excluded list, any temporary restraining order or interim suspension order sought or obtained in connection with my professional services, any public letter of reprimand, or any form of restriction, probation, suspension or revocation of licensure, membership, or clinical privileges by any healthcare entity; any revocation of my DEA license; a conviction for any crime; any action against my certification under the Medicare or Medicaid programs; or any cancellations, non-renewal or material reduction in medical liability insurance policy coverage.

I hereby affirm that in connection with the credentialing process, I have had made available to me and agree to abide by (1) the corporate bylaws (hospital applications only); (2) the professional and/or medical staff bylaws; (3) the rules and regulations; and (4) the policies and procedures of the Healthcare Organization applicable to my activities as long as I am affiliated with the Healthcare Organization. I also agree to abide by all applicable federal and state laws and regulations as long as I am affiliated with the Healthcare Organization. I also affirm that the information submitted in this application and any addenda thereto is current, complete and accurate and true to the best of my knowledge and belief and is furnished in good faith. I understand that I, as an applicant, have the burden of producing, in a timely manner, adequate information for proper evaluation of my professional competence, character, ethics and other qualifications and for resolving any doubt about such qualifications and that any omissions or misrepresentations may result in an automatic denial of my application or termination of any membership or privileges, employment or physician participation agreement. Finally, I understand that this application will not be processed until deemed completed by the Healthcare Organization.

Applicant Name:

Applicant Signature: