I hereby specifically authorize and consent for the following organizations to release to Med Advantage any and all records and information in your possession, which relates to my credentials as a physician and/or healthcare provider. The purpose of this authorization and consent to release is to permit Med Advantage to properly gather and verify my credentials to engage in the delivery healthcare or practice medicine.
State Licensing Organizations
License, Sanctions, State Requirements for Licensing, Education
Universities/Colleges/Graduate
Education and Training
Hospitals/Medical Facilities
Appointment Date/Privileges/Restrictions/Residency – Fellowship – Internship
Professional Liability Carrier
Certificate of Insurance that includes my professional liability insurance coverage history, which includes policy number, effective dates, limits of liability, and retroactive date.
Additional
The National Practitioner Data Bank, Federation of State Medical Boards, and Medicare/Medicaid for sanctions.
The purpose of this authorization and consent to release is to permit Med Advantage to properly gather and verify my credentials in accordance with the guidelines established by the National Committee on Quality Assurance (NCQA) and the Joint Commission Accreditation for Hospital Organizations (JCAHO). I hereby authorize and consent to Med Advantage providing any and all such information concerning my credentials to the healthcare organization, i.e., HMO, PPO, Hospital, etc., seeking to credential me for healthcare privileges. I hereby release any and all individuals, organizations and entities from any and all liability which might arise from their
furnishing such information and records to a third-party if such release is done at my request.
I agree to notify Med Advantage of any change in information.
I agree that this authorization and consent shall remain valid and in full force and effect until specifically withdrawn by me in writing.
I agree that a photocopy of this document will serve as a duplicate original.