Joe P Thompson
999 555 1111
666 555 4444
Claims Information if Any
Date of alleged error:
Location of alleged error:
Other parties involved (Other defendants):
Name of insurer:
Address of insurer:
City of insurer:
State of insurer:
Zip of insurer:
Status of complaint:
Total payment if applicable:
Description of claim (please give a complete narration of the claim including the following: alleged act or error upon which claimant bases claim, description of the type and extent of injury or damage allegedly sustained, patient’s condition at time of your involvement, patient’s condition at end of your treatment):
Consent, Authorization for Release of information and release of liability:
The purpose of this form is for you to grant authority for Medical Resource staffing LLC, employes, representatives and affiliates to gather information from various sources regarding your professional skill, competence and qualifications. It is important that you carefully read and understand this form before signing.
I hereby affirm and acknowledge under the penalties of perjury that the information provided by me on this application and questionnaire is correct, true and complete. I acknowledge that Medical Resource Staffing LLC will rely on the completeness and truthfulness of the information I have provided in evaluating my application and potential placement with Medical Resource Staffing LLC as a locum tenens provider.
By signing the form, I hereby authorize Medical Resource Staffing LLC, employees, representatives and affiliates to obtain and gather information regarding my personal character, ethics, education, training, medical acumen, professional affiliations, professional skill, professional competence, licensure, certificates, criminal history, health and professional liability insurance coverage, claims and litigation history.
I understand and acknowledge that Medical Resource Staffing LLC and specific employees and and representatives will contact and obtain written and/or verbal information from a wide variety of my sources in order to gather this information, including but not limited to: State medical or licensure boards, national practitioner data bank, government databases and exclusion lists, state and federal regulatory agencies and courts, educational and training institutions, professional boards and societies, mentors, peers and former professional relations, medical staff, including department heads, chairs and direct supervisors, insurers, employers and credit report, and if applicable monitor treatment programs.
I consent and authorize the release of all information listed above to Medical Resource Staffing LLC. I further understand the Medical Resource Staffing LLC may use this information for any lawful purpose associated with the processing and review of my application, including but not limited to disclosure to individuals or committees involved in the review of my application.
I release and discharge Medical Resource Staffing LLC, their representative, employees, governing bodies, clients and affiliates whether or not designated by these titles, and all other persons or entities supplying information information to them from liability or claims of any kind or character in any way arising out of inquiries concerning me or disclosures made in good faith in connection with my application. I am also waiving my right of action or other means of redress I may have against any person or entity supplying this information concerning my background to Medical Resource Staffing LLC or any of their entities to which I am applying as a locum tenens provider. I acknowledge that the decision to be granted a contract as a locum tenens provider with Medical Resource Staffing LLC is solely and completely at the discretion of Medical Resource Staffing LLC.
I authorize Medical Resource Staffing LLC to present my resume for potential assignment as a locums tenens provider at the facility/client of interest as agreed.