HR Credentialing Agreement

HR Credentialing Agreement

This HR Credentialing Agreement (the Agreement) is entered into by and between: Employer Name: and Applicant Name: . Effective Date:

Recitals

WHEREAS, Employer maintains a formal credentialing program to verify qualifications, licensure, education, employment history, professional references, and other information necessary to determine the Applicant's eligibility for appointment, hiring, or assignment; and

WHEREAS, Applicant seeks credentialing and hereby authorizes Employer and its agents to verify, collect, and rely upon information submitted in support of Applicant's credentialing application.

Definitions

"Credentialing" means primary source verification of licensure, education, training, board certification, work history, and related credentials, including but not limited to background checks, sanctions checks, and malpractice history.

Personal Information

Position Information

Licensure, Certification, and Privileges

Applicant hereby attests that the information supplied below is true and authorizes Employer to verify primary source documentation and to obtain copies of public records and relevant files.

Employment History (Most Recent)

Education

References

Provide three professional references capable of commenting on clinical competence and professional conduct.

Legal Disclosures and Authorizations

Applicant certifies that all statements and representations contained in this Agreement and any attachments are true, complete, and correct to the best of Applicant's knowledge. Applicant understands that any materially false statement, omission, or misrepresentation may result in denial of credentialing, termination of appointment, or other corrective action.

Applicant authorizes Employer, its authorized agents, credentialing committees, and third-party verifiers to obtain and evaluate information from educational institutions, licensing authorities, past and present employers, malpractice insurers, law enforcement agencies, and other sources deemed necessary to verify qualifications and fitness for appointment or employment.

By selecting the options below, Applicant provides express consent and release:

I consent to criminal background checks, verification of professional licensure, sanctions and exclusions checks, and primary source verification.

I authorize release of employment records and professional references to Employer and its agents.

I authorize release of malpractice claim information and peer review materials as necessary for credentialing.

Sanctions, Disciplinary Actions, and Claims

Applicant must disclose any current or prior disciplinary action, investigation, license restriction, loss of privileges, criminal conviction, or pending litigation involving professional services. Provide details below; if none, enter "None."

Confidentiality and Data Use

Applicant acknowledges that information collected during credentialing may be maintained in Employer's records and used for quality assessment, peer review, and regulatory compliance. Employer will use reasonable administrative safeguards to protect confidential information consistent with applicable law.

At-Will Employment and Equal Opportunity

Nothing in this Agreement is intended to alter the at-will employment relationship unless a separate written contract expressly states otherwise. Employer is an equal opportunity organization and does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, or any other protected characteristic.

Applicant Certification and Authorization

I certify that all information provided on this Agreement and attachments is true, complete, and accurate. I authorize Employer to verify any and all information provided, to conduct background and credentialing investigations, and to obtain references and records as necessary. I release from liability all individuals and organizations that provide information in good faith pursuant to this authorization.

Applicant Printed Name:

Applicant Signature:    Date:

Additional Documents Attached

Check all that accompany this Agreement:

Curriculum Vitae (CV)

Copy of Current Professional License

Board Certification / Certificates

Proof of Malpractice Insurance

Recredentialing and Ongoing Obligations

Applicant agrees to report within 30 days any material change in licensure status, privileges, malpractice claims, criminal charges, or other matters that may affect continued credentialing. Employer may require periodic recredentialing, monitoring, or additional documentation at Employer's discretion.

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