Healthcare Credentialing Authorization

HEALTHCARE CREDENTIALING AUTHORIZATION

Client Name:   Credentialing Contact:

Applicant / Provider Information

Date of Birth:   Social Security (last 4):

Phone:   Email:

Scope of Authorization

I, the undersigned Applicant, authorize any hospital, medical staff office, clinic, health care practitioner, medical group, facility, educational institution, malpractice carrier, insurance company, state licensing board, law enforcement agency, and any persons or entities with records concerning me to release to the requesting entity named above and its designated representatives any and all records and information necessary for evaluation of my credentials and qualifications for clinical privileges, participation in networks, or other credentialing actions. This authorization includes, but is not limited to, records relating to professional competence, licensure, employment, education, training, malpractice claims and settlements, disciplinary actions, criminal history, and health records that bear on my ability to perform professional duties.

The scope of this authorization includes verbal and written communications, copies of medical and billing records, peer review and credentialing committee records, and investigative files. I authorize release of the requested information regardless of whether such information would otherwise be protected from disclosure by professional privilege or privacy laws.

HIPAA Authorization and Notice

I authorize disclosure of my protected health information as described above for the purpose of credentialing, privileging, payor enrollment, contracting, peer review, and quality assessment. I understand that the information disclosed may include sensitive or otherwise protected information. I understand that the requesting entity may use or re-disclose the information disclosed pursuant to this authorization only as permitted by law; however, redisclosure by the recipient may not be protected by federal privacy regulations.

I understand that I may revoke this authorization in writing at any time except to the extent action has already been taken in reliance upon it. To revoke this authorization, I must provide a signed written notice to the requesting entity. This authorization will remain in effect until the earlier of (1) the credentialing determination is completed, or (2) the authorization expiration date provided below.

Attestations and Disclosures

By checking the boxes below and signing this Authorization I attest to the following statements and authorize the listed inquiries necessary for credentialing decisions:

I certify that the information I have provided in connection with credentialing and in this authorization is true, correct, and complete to the best of my knowledge.

I authorize verification of malpractice claim history, including claims, suits, settlements, judgments, arbitration awards, and pending matters.

I authorize inquiry of state licensing boards, disciplinary bodies, Medicare/Medicaid exclusion lists, and other regulatory entities for sanctions, restrictions, or adverse actions.

I authorize criminal background checks and verification of professional conduct as required for credentialing.

Additional Consents

I release from liability any person or entity that provides information in good faith pursuant to this authorization. I further authorize the requesting entity to share credentialing results, deliberations, and related information with other hospitals, payers, credentialing organizations, and authorized third parties for the purpose of assessing my qualifications. I understand that falsification, omission, or misrepresentation of material information is grounds for denial of privileges, termination of appointment or contract, and may be subject to legal penalties.

Entities Authorized to Release Information

Hospitals and affiliated medical staff offices

Insurance carriers and malpractice insurers

State licensing and disciplinary boards

Educational institutions and training programs

Other:

Acknowledgment

I acknowledge that I have read and understand this Authorization. I understand that signing this form is voluntary but that refusal to sign may limit the requesting entity's ability to process my credentialing application. I authorize the release of the requested information as described herein and consent to the uses and disclosures set forth above.

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