I hereby authorize the following individuals and entities to release all information (documented, oral or other) about me in their possession to Interim Physicians, LLC or its agents:
- All hospitals at which I have ever held privileges, whether full or limited, temporary or permanent; and all hospitals at which I have ever received training.
- All medical/osteopathic societies, education institutions, specialty boards, and other medical/osteopathic organizations with which I have been associated.
- All other State or Canadian licensure boards, including the Federation of State Medical Boards, federal health agencies, and federal and state drug control agencies.
- All licensed physicians, nurses or other health care professionals of any state or Canadian province.
- All attorneys who have participated in civil or criminal actions in which I was named party.
I hereby release the above named individuals and entities from all liability for the release of information to Interim Physicians, LLC and its agents. I further release from liability any group or individual that provides information relating to my ability as a healthcare professional. I authorize Interim Physicians, LLC to release information as needed to facilities, entities and medical organizations in the process of pursuing work in my profession and/or obtain hospital privileges, licensure or other medical professional qualifications on my behalf.
I further authorize Interim Physicians, LLC or any of its duly authorized agents to make any investigations that they deem necessary to secure information concerning me which is relevant to the requirements for credentialing, and I further authorize them to release such information they now or in the future have concerning me to (i) any federal, state, county, or local governmental entity, (ii) any hospital or other health care facility, or (iii) any other person upon a showing that the release of this information is vital to the health, safety and welfare of the general public.