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 Gadrian Corporation 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 Gadrian Corporation 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 Gadrian Corporation 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I agree that this authorization and consent shall remain valid and in full force and effect until specifically withdrawn by me in writing.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.