Release and Attestation
Release of Information and Attestation The undersigned has requested that HPA Healthcare assist him/her in obtaining professional liability (medical malpractice) insurance coverage, licensure, credentialing, privileging, and all other requirements necessary to participate in locum tenens or other travel assignments, and attests and affirms the following:
1. Application Accuracy & Updates
That the statements set forth in the Application(s) provided to the insurance company, hospital, health system, licensing board, or other regulatory body are true and correct. The undersigned agrees that in the event any information changes between the date of the Application and the effective date of issuance of coverage, licensure, privileges, or assignment, he/she will immediately notify HPA Healthcare in writing. The undersigned acknowledges and understands that the insurance company, hospital, licensing board, or credentialing entity may withdraw or change any outstanding quotes, authorizations, or agreements to bind coverage or grant privileges as a result of such changes.
2. No Binding Obligation Until Final Issuance
That the execution of any Application does not bind the undersigned, HPA Healthcare, the insurance company, or any facility to provide the requested coverage, privileges, or assignment. It is acknowledged and agreed that the information contained in the Application forms the basis of the issuance of any policy, license, or privileges should they be granted. All written statements and materials provided by the undersigned in conjunction with the Application are incorporated herein by reference.
3. Authorization to Obtain Information
That the undersigned authorizes HPA Healthcare to make inquiries of, and obtain information from, any and all:
- Professional references, employers, and prior contracting entities
- Medical schools, residency/fellowship programs, and training institutions
- State and federal licensing and regulatory boards
- Hospitals, health systems, and other facilities where the undersigned has held privilege
- Professional liability carriers and claims history repositories (e.g., NPDB)
- Government agencies for sanction/exclusion checks (e.g., OIG, SAM, Medicare/Medicaid)
- Background check vendors, drug screening labs, and other verification services
- Operative and procedural case logs, productivity reports, and related documentation from any training institutions, hospitals, or health systems where the undersigned has trained, practiced, or held privileges
The undersigned agrees to execute any additional documents as may be required to allow HPA Healthcare to obtain the above information, and further authorizes any person, institution, or agency to release such information upon request by HPA Healthcare.
4. Authorization to Release Information
That it is acknowledged and agreed by the undersigned that HPA Healthcare may release, transmit, or disclose any and all such information obtained—including but not limited to applications, references, claims history, case logs, background reports, health records, and verifications—to:
- Insurance carriers and underwriters
- State licensing boards
- Hospitals, health systems, and credentialing committees
- Payors and enrollment entities
- Any other parties reasonably necessary to facilitate the undersigned’s placement in a locum tenens or travel assignment.
5. Consent for Background, Drug, and Health Information
That the undersigned authorizes HPA Healthcare to obtain, review, and release the following, as may be required for assignment or credentialing:
- National, state, and county criminal background checks
- Federal sanctions/exclusion checks
- Drug and alcohol testing results
- Immunization history, TB testing, titers, physical exam, and occupational health screening information
- Any other records reasonably required for participation in assignments
6. Consent for Electronic Records & Signatures
That the undersigned consents to the use of electronic signatures and electronic record storage (including DocuSign, Bullhorn, MyLocker, or similar platforms) for the execution and transmission of applications, authorizations, and supporting documents, and agrees that a photocopy, scanned copy, or facsimile of this authorization shall be considered as valid as the original.
7. Duration & Validity
That this authorization shall remain valid for a period of five (5) years from the date of signature unless revoked in writing, and shall survive the termination of any individual assignment for purposes of insurance, credentialing, or compliance-related inquiries.
8. Hold Harmless
That the undersigned agrees to hold harmless and indemnify HPA Healthcare, and any person or institution furnishing information to HPA Healthcare, from any and all claims or actions that may arise from the release or use of such information in good faith for the purposes of credentialing, insurance, privileging, or assignment.
9. Attestation
By signing below, the undersigned attests and affirms that all information provided to HPA Healthcare, insurance carriers, licensing boards, hospitals, credentialing entities, and payors is true, correct, and complete to the best of his/her knowledge. The undersigned understands that any misrepresentation, misstatement, or omission may result in denial or termination of insurance coverage, licensure, hospital privileges, or assignment eligibility.