Healthcare HCP Certificate

HEALTHCARE HCP CERTIFICATE

Certificate Holder Information

Date of Birth:    Gender:

Primary Phone:    Email:

Employment and Licensure

Job Title:    NPI / Employee ID:

Professional License State:    License Number:    Expiration Date:

Immunization, Screening and Health Status

Influenza Vaccine Received:    Date Administered:

Tdap/Td (Tetanus/Diptheria/Pertussis) Received:    Date Administered:

MMR (Measles, Mumps, Rubella) Immunity or Vaccination:    Date/Proof:

Hepatitis B Series Completed:    Date of Series Completion:

Screening Method:    Date:

Result/Notes:

Medical History (for occupational health)

Certification, Authorization, and Limitations

The undersigned hereby certifies that the information provided above is true, correct, and complete to the best of their knowledge. The undersigned authorizes release of medical and immunization records necessary for credentialing, infection control, and occupational health purposes to the employer or credentialing facility named in this certificate. This authorization is limited to information reasonably necessary for verification of immunization status, tuberculosis screening, and fitness for duty.

I acknowledge that falsification of immunization or medical information may result in denial or revocation of clinical privileges, disciplinary action, or termination of contract. I understand that I may be required to comply with additional testing, vaccination, or temporary work restrictions as determined by the employer's occupational health program.

Examining Clinician / Program Representative (if applicable):    Date of Examination:

Authorization Expiration Date (if different from license):

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the facility's privacy notice and understand that my health information used or disclosed under this certificate will be handled in accordance with applicable privacy laws. I authorize release of the limited information described herein to the employer or credentialing bodies for purposes of infection control, credentialing, and occupational health monitoring.

Attestation by Certificate Holder

By signing below I attest under penalty of perjury that the statements made in this Healthcare HCP Certificate are true and accurate. I understand that this certificate may be relied upon by the employer, facility, credentialing organizations, and public health authorities.

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