ATTESTATION QUESTIONS:

Practitioners Name:

Please answer the following questions “Yes” or “No”. If your answer to any of the following questions is “Yes”, please provide details and reasons, as specified in each question, on a separate sheet. Please sign and date each additional sheet.

A	Has your license, certification, or registration to practice your profession, Drug Enforcement Administration (DEA) registration, or narcotic registration/certificate in any jurisdiction ever been denied, limited, suspended, revoked, not renewed, voluntarily or involuntarily relinquished, or subject to stipulated or probationary conditions, or have you ever been fined or received a letter of reprimand or is any such action pending or under review?	Yes No
B	Have you ever been suspended, fined, disciplined, or otherwise sanctioned, restricted or excluded for any reasons, by Medicare, Medicaid, or any public program or is any such action pending or under review?	Yes No
C	Have you ever been denied clinical privileges, membership, contractual participation or employment by any health care related organization*, or have clinical privileges, membership, participation or employment at any such organization ever been placed on probation, suspended, restricted, revoked, voluntarily or involuntarily relinquished or not renewed, or is any such action pending or under review?	Yes No
D	Have you ever surrendered clinical privileges, accepted restrictions on privileges, terminated contractual participation or employment, taken a leave of absence, committed to retraining, or resigned from any health care related organization* while under investigation or potential review?	Yes No
E	Has an application for clinical privileges, appointment, membership, employment or participation in any health care related organization* ever been withdrawn on your request prior to the organization’s final action?	Yes No
F	Has your membership or fellowship in any local, county, state, regional, national, or international professional organization ever been revoked, denied, limited, voluntarily or involuntarily relinquished or not renewed, or is any such action pending or under review?	Yes No
G	Have you ever had board certification revoked?	Yes No
H	Have you ever been the subject of any reports to a state or federal data bank or state licensing or disciplinary entity?	Yes No
I	Have you ever been charged with a criminal violation (felony or misdemeanor)?	Yes No
J	Have you ever practiced medicine without medical liability insurance?	Yes No
K	Do you now have, or have you recently had, any physical condition, mental health condition, or chemical dependency condition (alcohol or other substance) that affects or is reasonably likely to affect your current ability to practice, with or without reasonable accommodation, the privileges requested? If reasonable accommodation is required, please specify the accommodation(s) required on a separate sheet.	Yes No
L	Do you presently use any drugs illegally?	Yes No
M	Are you unable to perform any of the services/clinical privileges required by the applicable participating practitioner agreement/hospital appointment, with or without reasonable accommodation, according to accepted standards of professional performance?	Yes No
N	Have any professional liability claims or lawsuits ever been filed against you?	Yes No
O	Has your professional liability insurance ever been terminated, not renewed, restricted, or modified (e.g. reduced limits, restricted coverage, surcharged), or have you ever been denied professional liability insurance?	Yes No
P	Have you ever been court-martialed, investigated, sanctioned, reprimanded or cautioned by any military agency, been involuntarily terminated or forced to resign, or have you resigned voluntarily while under investigation or threat of sanction from any military agency?	Yes No

*e.g. hospital, medical staff, medical group, independent practice association (IPA), health plan, health maintenance organization (HMO), preferred provider organization (PPO), physician hospital organization (PHO), medical society, professional association, medical school faculty position or other health delivery entity or system

I certify the information in this entire application is complete, current, correct, and not misleading. I understand and acknowledge that any misstatements in, or omissions from this application will constitute cause for denial of my application or summary dismissal or termination of my clinical privileges, membership or practitioner participation agreement. A photocopy of this application, including this attestation, the authorization and release of any or all attachments has the same force and effect as the original. I have reviewed this information on the most recent date indicated below and it is true and complete to the best of my knowledge. While this application is being processed, I agree to update the information originally provided in this application should there be any change in the information. I agree to provide continuous care for my patients, until the practitioner/patient relationship has been properly terminated by either party, or in accordance with contract provisions.

AUTHORIZATION AND RELEASE OF INFORMATION FORM:

I understand and agree as follows:

1.	I understand and acknowledge that, as an applicant for medical staff membership and/or participation status with Rockwell Health LLC with whom I have, or wish to establish, a contractual relationship as a network provider, staff physician, or other provider of professional medical services, I have the burden of producing adequate information for proper evaluation of my competence, character, ethics, mental and physical health status, and other qualifications. In this application I have provided information on my qualifications, professional training and experience, prior and current licensure, Drug Enforcement Agency registration and history, and certification of CPR training if requested. I have provided peer references familiar with my professional competence and ethical character if requested. I have disclosed and explained any past or pending professional corrective action, licensure limitations or related matters, if any. I have reported my malpractice claims history, if any.
2.	I further understand and acknowledge that Rockwell Health LLC or Accrify will investigate the information in this application or that is on file. By signing this release form, I agree to such investigation and to the disciplinary reporting and information exchange activities of the Healthcare Organization(s)* as a part of the verification and credentialing process.
3.	I authorize all individuals, institutions and entities of other hospitals or institutions with which I have been associated and all professional liability insurers with which I have had or currently have professional liability insurance, who may have information bearing on my professional qualifications, ethical standing, competence, and mental and physical health status, to consult with Rockwell Health LLC / Accrify, their staffs and agents.
4.	I consent to the inspection of records and documents that may be material to an evaluation of qualifications and my ability to carry out the clinical privileges/services I request. I authorize each and every individual and organization in custody of such records and documents to permit such inspection and copying. I am willing to make myself available for interviews if required or requested.
5.	I release from any liability, to the fullest extent permitted by law, all persons for their acts performed in a reasonable manner in conjunction with investigating and evaluating my application and qualifications, and I waive all legal claims against any representative of the Healthcare Organization(s)* or their respective agent(s) to include Rockwell Health LLC / Accrify who acts in good faith and without malice in connection with the investigation of this application.
6.	I understand and agree that the authorizations and releases given by me herein shall be valid so long as I am an applicant for or have medical staff membership and/or clinical privileges/participation status at Rockwell Health LLC, unless revoked by me in writing.
7.	For hospital or medical staff membership/clinical privileges, I acknowledge that I have been informed of, and hereby agree to abide by, the medical staff bylaws, rules, regulations and policies.
8.	I agree to exhaust all available procedures and remedies as outlined in the bylaws, rules, regulations, and policies, and/or contractual agreements of Rockwell Health LLC where I have membership and/or clinical privileges/participation status before initiating judicial action.
9.	I further acknowledge that I have read and understand the foregoing Authorization and Release. A photocopy of this Authorization and Release shall be as effective as the original and authorization constitutes my written authorization and request to communicate any relevant information and to release any and all supportive documentation regarding this application.