STANDARD AUTHORIZATION, ATTESTATION AND RELEASE
I understand and agree that, as part of the credentialing application process for consideration of placement as a locum tenens or permanent direct hire employee (hereinafter, referred to as “Participation”) at, with or through:
Camden Healthcare Staffing
Camden Healthcare Community Staffing
AJ Riggins Health Search
(HEREINAFTER, INDIVIDUALLY REFERRED TO AS THE “ENTITY”)
and any of the Entity’s affiliated entities, I am required to provide sufficient and accurate information for a proper evaluation of my current licensure, relevant training and/or experience, clinical competence, health status, character, ethics, and any other criteria used by the Entity for determining initial and ongoing eligibility for Participation. In consideration of my Participation the information obtained relating to the application process will be shared with clients of the Entity at which I am being considered.
I further acknowledge and understand that my cooperation in obtaining information and my consent to the release of information do not guarantee that any Entity will grant me a position or contract, of any type, with me as a provider of services. I understand that my application for Participation with the Entity is not an application for employment with the Entity and that acceptance of my application by the Entity will not result in my employment by the Entity.
Authorization of Investigation Concerning Application for Participation.
I authorize the following individuals including, without limitation, the Entity, its representatives, employees, and/or designated agent(s); the Entity’s affiliated entities and their representatives, employees, and/or designated agents; and the Entity’s designated professional credentials verification organization (collectively referred to as “Agents”), to investigate information, which includes both oral and written statements, records, and documents, concerning my application for Participation. I agree to allow the Entity and/or its Agent(s) to inspect all records and documents relating to such an investigation.
Authorization of Third-Party Sources to Release Information Concerning Application for Participation.
I authorize any third party, including, but not limited to, individuals, agencies, medical groups responsible for credentials verification, corporations, companies, employers, former employers, hospitals, health plans, health maintenance organizations, managed care organizations, law enforcement or licensing agencies, insurance companies, educational and other institutions, military services, medical credentialing and accreditation agencies, professional medical societies, the Federation of State Medical Boards, the National Practitioner Data Bank, and the Health Care Integrity and Protection Data Bank, to release to the Entity and/or its Agent(s), information, including otherwise privileged or confidential information, concerning my professional qualifications, credentials, clinical competence, quality assurance and utilization data, character, mental condition, physical condition, alcohol or chemical dependency diagnosis and treatment, ethics, behavior, or any other matter reasonably having a bearing on my qualifications for Participation in, or with, the Entity. I authorize my current and past professional liability carrier(s) to release my history of claims that have been made and/or are currently pending against me. I specifically waive written notice from any entities and individuals who provide information based upon this Authorization, Attestation and Release.
Authorization of Release and Exchange of Disciplinary Information.
I hereby further authorize any third party at which I currently have Participation or had Participation and/or each third party’s agents to release “Disciplinary Information,” as defined below, to the Entity and/or its
Agent(s). I hereby further authorize the Agent(s) to release Disciplinary Information about any disciplinary action taken against me to its participating Clients at which I am being considered, and as may be otherwise
required by law. As used herein, “Disciplinary Information” means information concerning: (I) any action taken by such health care organizations, their administrators, or their medical or other committees to revoke, deny, suspend, restrict, or condition my Participation or impose a corrective action plan; (ii) any other disciplinary action involving me, including, but not limited to, discipline in the employment context;
or (iii) my resignation prior to the conclusion of any disciplinary proceedings or prior to the commencement of formal charges, but after I have knowledge that such formal charges were being (or are being) contemplated and/or were (or are) in preparation.
Release from Liability.
I release from all liability and hold harmless any Entity, its Agent(s), and any other third party for their acts performed in good faith and without malice unless such acts are due to the gross negligence or willful misconduct of the Entity, its Agent(s), or other third party in connection with the gathering, release and exchange of, and reliance upon, information used in accordance with this Authorization, Attestation and Release. I further agree that any Entity, any Agent(s), or any other party involved in the credentialing/application or placement process is entitled to absolute immunity from suit. I agree not to sue any party for their acts, defamation or any other claims based on statements made in good faith and without malice or misconduct of such Entity, Agent(s) or third party in connection with the credentialing process or placement process. This release shall be in addition to, and in no way shall limit, any other applicable immunities provided by law for peer review and credentialing activities.
Candidate accepts and agrees that the specific identity (the actual name) of all hiring practices and all related jobs available is confidential information and is not to be disclosed to any third parties prior to accepting employment. The term "confidential" includes without limitations, all clients and available jobs learned through communications with AJ Riggins Health Search, or Camden Healthcare Staffing.
Candidates considering placement in positions either temporary or direct hire, referred by the Entity, should exercise independent judgment as to the value of such positions. Information advertised, in most cases, is supplied to the Entity without proof and without audit. Data including, but not limited to, revenues, number of patients, support staff, compensation, benefits, employment practices, political and religious affiliations, career path and expected earnings, should all be investigated directly with the hiring practice, as well as the background and record of practices and their owners. Therefore you agree and acknowledge that Entity cannot be held responsible for inaccurate or incomplete information, and that you assume full responsibility for any decisions made based upon this information. Further you agree and acknowledge that you hold harmless, and grant absolute immunity from suit AJ Riggins Health Search, Camden Healthcare Staffing, AJ Riggins Company, AJ Riggins Search Group LP, their officers, directors, employees and agents, from any and all liability, loss, damage or expense as a result of any and all dealings you have with the Entity, including but not limited to you accepting an associateship, partnership, locum tenens assignment, or ownership referred by the Entity.
Candidate accepts and agrees that the Entity is not an employment agency, does not charge a fee to job seekers, and does not represent job seekers in the marketplace, but rather represents the hiring organization(s). Candidate accepts and agrees that he/she is subject to a selection process, both by the Entity the Entity’s client(s) (hiring organization(s)). Candidates are chosen for presentation to clients at the sole discretion of the Entity, and candidates are selected for interview at the sole discretion of the Entity’s client/hiring organization(s). In regard to this selection process by the Entity and Entity’s client, you agree and acknowledge that you hold harmless, and grant absolute immunity from suit to AJ Riggins Health Search, Camden Healthcare Staffing, AJ Riggins Company, AJ Riggins Search Group LP, their officers, directors, employees and agents.
I agree that information obtained in accordance with the provisions of this authorization, Attestation and Release is not and will not be a violation of my privacy.
I certify that all information provided by me in my application is true, correct, and complete to the best of my knowledge and belief. I understand and agree that any material misstatement or omission in the application may constitute grounds for withdrawal of the application from consideration; denial or revocation of Participation; and/or immediate suspension or termination of Participation. This action may be disclosed to the Entity and/or its Agent(s).
I further acknowledge that I have read and understand the foregoing Authorization, Attestation and Release. I understand and agree that a facsimile or photocopy of this Authorization, Attestation and Release shall be as effective as the original.