Postgraduate Physician Assistant Critical Care Residency Program Application Form (Page 2 of 4) in pdf

Postgraduate Physician Assistant Critical Care Residency Program Application Form Page 2

AUTHORIZATION AGREEMENT

I hereby authorize The Johns Hopkins Hospital (JHH), the medical staff(s) at JHH-operated facilities

and their representatives to consult with administrators and members of the medical staff of other

hospitals or institutions with which I have been associated and with others, including past and present

malpractice carriers, who may have information bearing on my clinical competence, character, and

ethical qualifications. I also consent to the inspection by Johns Hopkins Hospital, the medical staff(s)

at JHH-operated facilities and its representatives of records and documents that may be material to

an evaluation of my qualifications for staff membership. I hereby release from liability any and all

individuals and organizations who provide, in good faith, information to Johns Hopkins Hospital or the

medical staff(s) at JHH-operated facilities, and I hereby consent to their release of such information to

all personnel involved in the credentialing process at any other facility to which the applicant has

applied and which is a part of the Johns Hopkins Hospital.

I understand that additional information concerning my health may be required for the consideration of

this application, and that my health as it relates to my ability to perform my medical staff duties

appropriately will be an ongoing consideration.

I agree that my activities as a member of the medical staff will be bound by the provisions of the

Institutional Bylaws, Rules & Regulations, and Code of Conduct. I understand that any significant

misstatement in or omission from this application will constitute cause for immediate denial of

appointment or summary dismissal from this Program.

I consent to the release of information provided in this application to any insurance plan in which JHH,

or a component of JHH, is a participating entity, subject to JHH receiving from the plan an

authorization for the release of such information, which I have executed.

I hereby declare that the statements in this application and all attachments hereto are complete and

accurate.

________________________________________

_________________________

Signature of Applicant

Date

Postgraduate Physician Assistant Critical Care Residency Program Application Form Page 2