Has your license to practice, DEA, state narcotic license, or board certification in your profession ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation, or have you ever been subject to a consent order, probation, or any conditions/limitations by any state licensing board?
Have your clinical privileges or medical staff membership at any hospital or healthcare institution ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical records when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff committee or governing board?
To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank?
Have you had any malpractice actions (pending, settled, arbitrated, mediated or litigated)?
Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony including an act of violence, child abuse or a sexual offense?
Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety?
By my signature below, I authorize Rhino Medical Services to conduct background and reference checks on me regarding any information related to possible placement as a healthcare provider. This includes information on my education, licensing, work history, Medicare/Medicaid sanctions, malpractice claims and insurance eligibility, and criminal history. Rhino Medical Services may gather the information from various sources including, but not limited to, consumer reporting agencies, hospitals, medical institutions or organizations, personal references, physicians, employers (past and present), business and professional associates (past and present), governmental agencies and instrumentalities (local, state, federal, or foreign), university transcript offices, medical schools, and the Office of the Inspector General.
I authorize Rhino Medical Services to confirm information contained on any document that I provide Rhino Medical Services, including my curriculum vitae. I consent to Rhino Medical Services sharing this information with Rhino Medical Services clients and affiliates. I understand that upon my request Rhino Medical Services will disclose the nature and scope of information contained in my file in accordance with federal law. A request for disclosure of information in my file must be made in writing and directed to my recruiting consultant.
I authorize the above-named entities and individuals to release to state licensing boards, hospitals, and Rhino Medical Services, any information (written or oral), including medical information, files or records about me in their possession required for evaluation of my qualifications for placement as a locum tenens provider. I hereby release the above-named individuals and entities, including Rhino Medical Services, from all liability for the release of information to any state licensing board, hospital, or its agents.
I further authorize Rhino Medical Services, its agents, and affiliates to release this information, including medical information, to federal, state, county, or local government entities, hospitals or other healthcare facilities, insurance providers or any other person upon showing that the release of information is vital to the general public’s health, safety and welfare.
I make this release for the purpose of allowing Rhino Medical Services to assist in my request for a license to practice in my specialty and/or to assist in my efforts to work as a healthcare provider for Rhino Medical Services clients.