Authorization and Consent
In making this application:
- I acknowledge my obligation to fulfill my responsibilities to provide continuous quality care to patients of DCC,
- to make decisions as appropriate to the patient’s needs, to maintain practice knowledge and skills current through continuing education opportunities,
- to abide by the bylaws, rules and regulations, policies and procedures of the clinic,
- to participate in and cooperate fully with the Quality Assurance Program and all programs to improve quality and reduce risks.
I agree to participate
- in the review of records and documents relating to patient care and services, and
- to subject my performance to the review by the Clinic and its representatives for the purpose of improving the quality of care and services and reducing risk.
I hold the Clinic and its representatives free of all liability for such actions.
I hereby release from liability DCC and all its representatives for their acts performed while evalua- ting my application, credentials and qualifications.
I hereby release from any liability any and all individuals and organizations that provide information to DCC or its representatives concerning my professional competence, character, ethics, and other qualifications for employment and/or privileges and I hereby consent to the release of such infor- mation.
As applicable, I hereby accept that I will abide by the requirements for medical malpractice coverage for the Federal Tort Claims Act. I will cooperate fully in all measures to improve quality and reduce risks, and with any investigations and defense of liability claims.
I understand that I have the burden of producing adequate information for the proper evaluation of my professional competence, character, ethics and other qualifications, and for resolving any doubts about such qualifications. I fully understand that any misstatements or omissions in the application constitute cause for denial or termination of privileges and/or employment. All information submitted by me in the application is true to the best of my knowledge.
