Thank you for your interest in joining the Provider Panel. Please fill out the application below.

Consent Form

Upon the signing of this application, I represent that all of the information now or hereafter given by me in support of my application is true, correct and complete to the best of my knowledge and belief. I agree to promptly notify {{ALL}} if there are any material changes in the information provided, whether prior to or after acceptance as a {{ALL}} participating provider. I hereby authorize the release of any information from any source including but not limited to information from individuals, peers, customers, companies, institutions, agencies, data banks or references who may have information bearing on my moral and ethical qualifications and competence to carry out the privileges I have requested, and I authorize them to release such information as you require, including my prior disciplinary records, for purposes of verifying information obtained in the attached application or any re-application information without any obligation to give me written notice of such disclosure. I agree to hold {{ALL}} and the informant harmless from any liability to me and/or my organization for providing such information.

I hereby further authorize {{ALL}} to release any and all information related in any way to my professional practice to any person, entity or governmental agency which: (a) provides {{ALL}} with an authorization signed by me; or (b) has a legal right to know under any state or Federal law. I agree to hold {{ALL}} harmless from any liability for providing any such information as specified herein.

I release all parties from all liability from any damages, causes of action, including, but not limited to, slander and libel, that may result from furnishing any information to you. I agree that any false information in support of my application may result in action up to and including cancellation of any or all contracts subject to contract provisions regardless of when discovered by {{ALL}}. I release {{ALL}}, the their Credentialing Committee{{PLURAL/SINGLE}}, individually and collectively, from any and all liability from any damages and/or causes of action associated with the {{ALL}} credentialing and privileging process.

I hereby signify my willingness to appear for interviews with {{ALL}}. I fully consent to the inspection of any and all records and documents pertinent to my application for appointment and/or privileges. If there is a doubt as to my competence, morals, or ethics, the burden shall be on me to resolve the same. I understand and agree that if {{ALL}} determines that this application contains any significant misstatements, misrepresentations, or omissions, {{ALL}}’s acceptance of this application for participation and any subsequent participating provider agreement which {{ALL}} enters into with me will be voidable at {{ALL}}’s sole discretion.

I understand and agree that: (a) I have the burden of producing all information required or requested by {{ALL}} in connection with this application; (b) {{ALL}} {{IS/ARE}} under no obligation to complete the processing of this application until all information requested is provided; (c) {{ALL}} {{HAS/HAVE}} the sole discretion to determine whether or not I or my organization will be accepted as a participating provider; and (d) in the event that {{ALL}} decides not to accept me or my organization as a participating provider, I may initiate administrative appeal procedures as defined in the instructions for completing the application.

I understand and agree that the certifications, authorizations and other provisions contained herein shall remain in force for so long as this application is pending and, if accepted for participation, for so long as my and/or my organizations’ provider agreement with {{ALL}} remains in force.

I understand that {{ALL}} {{IS/ARE}} not obligated to grant any or all requested privileges and that application for such is not a guarantee of a contract with {{ALL}}.