Release from Liability:
I release from all liability and hold harmless any Entity, its Agent(s), and any other third party for their acts performed in good faith and without malice unless such acts are due to the gross negligence or willful misconduct of the Entity, its Agent(s), or other third party in connection with the gathering, release and exchange of, and reliance upon, information used in accordance with this Authorization, Attestation and Release. I further agree not to sue any Entity, any
Agent(s), or any other third party for their acts, defamation or any other claims based on statements made in good faith and without malice or misconduct of such Entity, Agent(s) or third party in connection with the credentialing process. This release shall be in addition to, and in no way shall limit any other applicable immunities provided by law for peer review and credentialing activities.
I fully release from liability any person or entity, including any and all representatives of the Entities and any representative, agent or component thereof, that requests or provides information in connection with the evaluation of my application, credentials and practice, to the fullest extent allowed by applicable statutes, regulations and judicial decisions. Moreover, I fully release from liability the participating Entities to which I am applying and any Agent or component thereof, and all other persons or Entities participating in the evaluation of my
credentials and practice from any and all liability for their actions and decisions, to the fullest extent allowed by applicable statutes, regulations and judicial decisions.
In this Authorization, Attestation and Release, all references to the Entity, its Agent(s), and/or other third party include their respective employees, directors, officers, advisors, counsel, and agents. The Entity or any of its affiliates or agents retains the right to allow access to the application information for purposes of a credentialing audit to customers and/or their auditors to the extent required in connection with an audit of the credentialing processes and provided that the customer and/or their auditor executes an appropriate confidentiality agreement. Except with respect to its application to protected health information or other confidential medical information, I understand and agree that this Authorization, Attestation and Release is irrevocable for any period during which I am an applicant for Membership or Participation at an Entity, a member of an Entity’s medical or health care staff, or a participating provider of an Entity. I agree to execute another form of consent if law or regulation limits the application of this irrevocable authorization. With respect to protected health information or other confidential medical information, this Authorization may be revoked and provided above. However, I understand that my revocation of this Authorization with respect to protected health information or other confidential medical information or my failure to promptly provide another consent with respect to any other information may be grounds for termination or discipline by the Entity in accordance with the applicable bylaws, rules, and regulations, and requirements of the Entity, or grounds for my termination of Membership or Participation at or with the Entity and will result in the cessation of any action on my application for Membership or Participation. I agree that information obtained in accordance with the provisions of this Authorization, Attestation and Release is not and will not be a violation of my privacy.
I certify that all information provided by me in my application is true, correct, and complete to the best of my knowledge and belief, and that I will notify the Entity and/or its Agent(s) within 10 days of any material changes to the information I have provided in my application or authorized to be released pursuant to the credentialing process. Further, I specifically agree to notify the Entities to which I am applying immediately upon notification upon any significant change or any formally recommended change in licensure status, or any actual or formally
recommended denial, suspension or revocation of privileges or membership or status by another healthcare entity, or cancellation or interruption of my professional liability insurance coverage. I understand that corrections to the application are permitted at any time prior to a determination of Membership or Participation by the Entity, and must be submitted on-line or in writing, and
must be dated and signed by me (may be a written or an electronic signature). I understand and agree that any material misstatement or omission, as determined solely by the Entity, in my application may constitute grounds for withdrawal of the application from consideration; denial or revocation of Membership or Participation; and/or immediate suspension or termination of Membership or Participation and will result in the cessation of any action on my application for Membership or Participation. This action may be disclosed to the Entity and/or its Agent(s).
I further acknowledge that I have read and understand the foregoing Authorization, Attestation and Release. I understand and agree that a facsimile or photocopy of this Authorization, Attestation and Release shall be as effective as the original.