Note: Entities affiliated with Salient MD include Salient Locums, LLC and Salient Health Services, Inc.
I hereby give permission to Salient MD and its Affiliated Entities and/or its designee to request information regarding my professional credentials and qualifications from educational facilities, the chief(s) of the clinical department(s) of the hospital(s) in which I currently have or formerly have had medical staff membership and/or clinical privileges, professional certification boards, state regulatory and licensing departments, professional liability insurance carriers, other professional monitoring entities, and present and past employers.
The information requested may include otherwise privileged or confidential material relative to my professional qualifications, credentials, claims history, clinical and/or professional competence, character, ethics, or any other matter having bearing on the credentialing procedure. I release and agree to hold harmless Salient MD and its Affiliated Entities to whom this information is given and their representatives, employees and agents from any and all liability for any damages, costs, and expenses which may result from the gathering or use of such information, as long as such release or use of information is done in good faith and without malice.
I hereby authorize the educational facilities, the chief(s) of the clinical department(s) of the hospital(s) in which I currently have or formerly have had staff privileges, professional certification boards, state regulatory and licensing departments, professional liability carriers, other professional monitoring entities and present and past employers to submit information requested by Salient MD and its Affiliated Entities including otherwise privileged or confidential material relative to my professional qualifications, credentials, past and present malpractice coverage, claims and suit information, clinical and/or professional competence, character, ethics, or any other matter having bearing on the credentialing procedure. I hereby further release and agree to hold harmless Salient MD and its Affiliated Entities, their representatives, employees and agents from any and all liability for any damages which may result from providing this information, as long as such release or use of this information is done in good faith and without malice. I further agree the burden shall be upon me to prove such release was done in bad faith and with malice by a preponderance of evidence.
I authorize Salient MD and its Affiliated Entities to obtain information about me from a consumer reporting agency for “engagement” purposes. I understand that I may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about my character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as my neighbors, friends, or associates. These reports may include employment history and reference checks, criminal and civil litigation history information, motor vehicle records (“driving records”), sex offender status, credit reports, education verification, professional licensure, drug testing, Social Security Verification, and information concerning workers’ compensation claims. I have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report.
I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this authorization and, if I am engaged, throughout my “engagement”. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Salient MD and its Affiliated Entities or another outside organization acting on behalf of Salient MD and its Affiliated Entities.
I hereby consent to submit to a drug or alcohol screening tests; and to furnish a sample of my urine, breath, and/or blood for analysis. The specific panel of tests shall be determined by Salient MD (or one of its Affiliated Entities and/or one of its Clients where I may be placed), consistent with either Salient MD’s or a Client’s Policy regarding the screening and credentialing of applicants. I further authorize and give full permission for the designated laboratory or other testing facility to release any and all results and documentation relating to such test to Salient MD. I authorize Salient MD to share these same results with any of their Clients wherein I am in the process of being credentialed. I understand that evidence of current use of illegal drugs, or excessive use of alcohol or any controlled substance, will prohibit me from being contracted with Salient MD or any of their client facilities. I further agree to hold harmless Salient MD and its agents from any liability arising in whole or part, out of the collection of specimens, testing, and use of the information from said testing in connection with Salient MD’s consideration of my application.
I agree that a photocopy or facsimile of this document with my signature may be accepted by any person or entity from which such information is sought with the same authority as the original and I specifically waive written notice from any such entities or individuals who may provide information based upon this authorized request.