Healthcare Qualifications Signature

HEALTHCARE QUALIFICATIONS SIGNATURE

This form documents acknowledgment by the patient that they have been informed about the professional qualifications and relevant clinical credentials of the named provider and that the patient authorizes verification of such credentials. Completion of this form does not substitute for informed consent to any specific procedure or treatment; it confirms receipt of qualifications information and voluntary authorization for verification and use as described below.

Patient Information

Male Female Other / Prefer not to say

Insurance Information

Medical History (Summary)

Provider Qualifications Summary

Provider Name:

Board certified Board name:

Malpractice Insurance

Training, Certifications & Dates

BLS Date:    ACLS Date:

PALS Date:    Other: Date:

Immunizations and Screening

Hepatitis B: Completed Declined Completion Date:

MMR Date:    Varicella Date:

Influenza (most recent):

TB Screening: PPD IGRA Test Date: Result: Negative Positive

Background & Disciplinary History

I affirm there is no history of professional sanctions, license suspension, revocation, or criminal conviction that would materially affect clinical privileges.

If yes, provide explanation below.

Authorization, Acknowledgment & Certification

By signing below, I acknowledge that I have been given the opportunity to review a summary of the provider's professional qualifications, including licensure, board certification status, specialty training, malpractice insurance coverage, and relevant training and immunization status. I authorize the facility or provider to verify credentials, training, licensing, malpractice coverage and disciplinary information from appropriate entities and release information necessary for credentialing and quality assurance.

I certify under penalty of perjury under applicable law that the information I have provided on this form is true and complete to the best of my knowledge. I understand that I may withdraw this acknowledgment or consent at any time by providing written notice; withdrawal does not invalidate any actions already taken in reliance upon my prior authorization. This acknowledgment does not limit my right to refuse recommended treatment nor does it waive any legal rights I may have under applicable law.

HIPAA / Privacy Acknowledgment: I acknowledge receipt of the facility's notice of privacy practices and authorize use and disclosure of my health information for treatment, payment and healthcare operations as described in that notice.

Authorization to Verify Credentials: I authorize verification of the provider's credentials and release of records related to credentialing and quality review for purposes of evaluating or auditing care provided.

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