Standard Authorization, Attestation, and Release
As part of the credentialing application process for participation and/or clinical privileges (“Participation”) I understand and agree to provide complete and accurate information necessary for the evaluation of my licensure, training, experience, clinical competence, health status, character, ethics, and other criteria relevant to initial and ongoing eligibility.
I acknowledge that each participating entity maintains independent criteria for acceptance, and that submission of this application does not guarantee clinical privileges or a contractual relationship. I further understand that this application is not for employment, and acceptance does not constitute employment with Synergy Health Partners LLC.
For hospital credentialing purposes, when applicable, I consent to appear for interviews with credentialing committees, medical staff leadership, hospital administration, or governing boards as requested. I affirm my commitment to continuous patient care and agree to abide by applicable hospital bylaws, rules, and policies.
Authorization for Credentialing Investigation
I authorize Synergy Health Partners LLC, its affiliates, designated agents, and credentialing verification organizations (“Agents”) to investigate all oral and written information related to my application. I consent to the inspection of all relevant records and documents.
Authorization for Third-Party Information Release
I authorize third parties—including but not limited to employers, hospitals, licensing boards, insurers, educational institutions, professional societies, and data banks—to release information regarding my qualifications, competence, professional conduct, and claims history to Synergy Health Partners LLC and its Agents. I waive any requirement for written notice from those providing such information.
Authorization for Disciplinary Information Exchange
I further authorize the release and exchange of disciplinary information, including actions taken to revoke, restrict, or condition my privileges; employment-related discipline; or resignation in anticipation of formal charges. I understand this information may be shared among participating entities and disclosed as required by law.
Release from Liability
I release Synergy Health Partners LLC, its affiliates, Agents, and third parties from liability for actions taken in good faith and without malice in connection with the credentialing process. This release supplements any legal immunities provided for peer review and credentialing activities.
Digital Credentialing Consent and Audit Access
I understand that this Authorization, Attestation, and Release may be executed and submitted electronically as part of a digital credentialing packet. I consent to the use of secure digital platforms for the collection, verification, and storage of credentialing data. I further acknowledge that application materials may be accessed by authorized customers or auditors for credentialing audits, subject to appropriate confidentiality agreements.
Duration and Revocability
This Authorization, Attestation, and Release remain irrevocable during any period of active application, participation, or affiliation with Synergy Health Partners LLC. If additional consent is required by law, I will provide it promptly or risk termination of Participation.
Certification and Notification Obligations
I certify that all information provided is true and complete to the best of my knowledge. I agree to:
• Notify Synergy Health Partners LLC or its Agents within ten (10) days of any material changes
• Submit corrections prior to final determination, signed and dated
• Accept that material misrepresentation may result in denial, suspension, or termination of services
Acknowledgment and Signature
I acknowledge that I have read and understand this Authorization, Attestation, and Release. I agree that a facsimile, photocopy, or digitally signed version shall be as valid as the original.