APPLICANT'S RESPONSIBILITY

I apply for medical staff membership, hospital and clinic privileges, and/or health plan network participation as requested above. I am willing to make myself available for interviews in regard to this application and intend to be legally bound by the terms of this Consent and Release.

I understand that it is my responsibility to produce adequate information so that Gundersen Lutheran Credentialing Services, Inc. (“GLCS”), the credentialing verification organization retained by Gundersen Health System, Inc., Gundersen Clinic, Ltd., Gundersen Lutheran Medical Center, Inc., Gundersen Health Plan, Inc., and certain other Health Care Organizations, can perform primary source verification of my qualifications. I agree to provide GLCS and such Health Care Organization(s) with updated information regarding all questions on the application form as new information becomes available. I also agree to provide GLCS and such Health Care Organization(s) with additional information that they may request which is relevant and material to my application. Failure to produce any requested information will prevent my application from being processed.

In making this application for appointment, privileges and network participation:

1. I acknowledge that I have had the opportunity to request, receive and read the by-laws of the participating Health Care Organization to which I am applying;
2. I pledge to provide continuous care to my patients;
3. I am familiar with the principles and standards of the Joint Commission, the National Committee on Quality Assurance (“NCQA”), and the principles, standards and ethics of the national, state and local associations and societies (“Professional Societies”) that apply to and govern my specialty;
4. I agree to be bound by the bylaws, rules and regulations of the participating Health Care Organization to which I am applying for medical staff membership, hospital or clinic privileges, and/or health plan network participation, and the principles and standards of the JCAHO, the NCQA and such Professional Societies without regard to whether or not I am granted membership or clinical privileges in all matters relating to the consideration of my application;
5. I agree to abide by such rules and regulations as may be from time to time adopted by the Health Care Organization(s) to which I am applying.

TERMS AND CONDITIONS OF APPOINTMENT AND PRIVILEGES

By applying for medical staff membership, hospital or clinic privileges, and/or health plan network participation with the Health Care Organization(s) to which I am applying, I accept the terms and conditions set forth below:

1. There is no guaranty that my application will be granted, in whole or in part;
2. My request will be evaluated in accordance with procedures in the applicable medical staff bylaws or policies, rules and regulations of the Health Care Organization(s) to which I am applying;
3. Medical staff recommendations relating to my application are subject to the final decision of the governing board(s) or designee(s) of the Health Care Organization(s) in question, whose decision will be final;
4. If my application is accepted, my initial appointment and clinical privileges will be provisional for the time period determined by the governing board(s) or designee(s) of the Health Care Organization(s) to which I am applying;
5. I have the responsibility to keep this application current by informing GLCS and the Health Care Organization(s) of any changes including, but not limited to, any change in my professional liability insurance coverage, the filing of a lawsuit against me and any change in my medical staff status at any other hospital, clinic or health plan;
6. My application and continued medical staff membership, hospital and clinic privileges and/or health plan participation remain contingent upon my continued demonstration of professional competence and cooperation, my general support of the Health Care Organization(s), acceptable performance of all related responsibilities, as well as the other factors deemed relevant by the governing board(s) or designee(s) of such organization(s).

RELEASE

By applying for medical staff membership, hospital and clinical privileges and/or health plan network participation, I accept the following conditions regardless of whether or not my application is granted, in whole or in part. These conditions shall remain in effect for the duration of any term of appointment I may be granted.

I release from liability and agree not to sue GLCS, its authorized representatives, and the Health Care Organization(s) to which I am applying for any actions, recommendations, reports, statements, communications, or disclosures involving me, which are made, taken, or received by GLCS, such Health Care Organization(s) or their respective authorized representatives relating to the following:

1. My application for hospital medical staff membership, health plan network participation, and hospital or clinic privileges, including temporary privileges;
2. Periodic reappraisals undertaken for reappointment or for increase or decrease in clinical privileges conducted in accordance with the applicable medical staff bylaws, rules, regulations and policies of the Health Care Organization(s) to which I am applying;
3. Proceedings relating to the revocation, suspension, limitation or reduction of my hospital or clinic privileges, the denial of my application for appointment, or any other disciplinary action conducted in accordance with the applicable medical staff bylaws, rules, regulations and policies of the Health Care Organization(s) to which I am applying;
4. Summary suspension of my medical staff membership, hospital or clinical privileges, or health plan network participation in accordance with the applicable medical staff bylaws, rules, regulations and policies of the Health Care Organization(s) to which I am applying;
5. Hearings and appellate reviews conducted in accordance with the applicable medical staff bylaws, rules, regulations and policies of the Health Care Organization(s) to which I am applying;
6. Hospital and medical staff quality assessment/improvement activities conducted in accordance with the applicable medical staff bylaws, rules, regulations and policies of the Health Care Organization(s) to which I am applying;
7. Utilization reviews conducted in accordance with the applicable medical staff bylaws, rules, regulations and policies of the Health Care Organization(s) to which I am applying;
8. Any other hospital, medical staff, department, service, or committee activities conducted in accordance with the applicable medical staff bylaws, rules, regulations and policies of the Health Care Organization(s) to which I am applying;
9. Inquiries concerning my professional qualifications, credentials, clinical competence, character, mental or emotional stability, physician condition, ethics, behavior, or any other matter that legally may be considered in connection with my application for medical staff membership, hospital or clinic privileges, or health plan network participation;
10. Inspection and/or verification of educational records, medical staff records, court records, licensing board records, professional liability insurance records, as well as contact with personal and/or professional references and any other records or third parties that may have direct bearing upon my application;
11. Any other matter that might directly or indirectly have an effect on my clinical competence, on patient care, or on the orderly operation of the Health Care Organization(s) to which I am applying.

I authorize GLCS, the Health Care Organization(s) to which I am applying, and their authorized representatives to contact any third party who may have information bearing on my professional qualifications, clinical competence, character, mental or emotional stability, physical condition, ethics, behavior and any other matter that legally may be considered in connection with my application. This authorization includes the right to inspect or obtain any information, documents, recommendations, reports, statements, or disclosures relating to my application held by hospitals, facilities, professional liability insurance companies, the National Practitioners Data Bank, the Federation of State Medical Boards, other centralized repositories of physician practice data, and other persons and organizations (hereafter referred to collectively as “Third Parties”) that may be relevant to my application. I authorize Third Parties to release such information and documents to GLCS, such Health Care Organizations and their authorized representatives, and release the Third Parties from liability for disclosing such information and documents. Upon request of the Health Care Organization(s) to which I am applying, I agree to appear for an interview.

It is the policy of GLCS to protect the confidentiality of credentialing files in accordance with all applicable legal requirements. All credentialing files will be maintained in GLCS's offices in locked filing cabinets under the custody of the Manager of Credentialing Services or an authorized designee. Access to these records is strictly controlled.

NOTICE OF APPLICANT'S RIGHTS

1. I understand that I have the right to review certain information obtained as part of the application process by GLCS and the Health Care Organization(s) to which I am applying including, for example, reports from the National Practitioner Data Bank and my professional liability claims history, professional liability coverage, educational background, work experience, and licensure. I also understand that I am not entitled to review peer review information, references and recommendations obtained as part of the application process.
2. It is my understanding that I have the right to correct any erroneous information provided on this application including, for example, actions on a license, malpractice history, suspension or termination of hospital privileges, or board certification status.

AFFIRMATION, AUTHORIZATION, RELEASE
A copy of this authorization and release shall have the same force and effect as the signed original.

I certify, warrant and represent that all of the information provided by me in or with this application is accurate and complete as of the date of my signature below. I understand that any misrepresentation, misstatement, or omission from this application, whether intentional or not, may cause rejection of this application by the Health Care Organization(s) to which I am applying and may result in denial of medical staff membership, hospital and clinic privileges, and/or health plan network participation. I also understand that, upon subsequent discovery of such misrepresentation, misstatement, or omission, the Health Care Organization(s) to which I am applying may terminate my medical staff membership, hospital and clinic privileges, and/or health plan network participation. I further acknowledge that I have read and understand the foregoing Consent and Release. This authorization is valid for 180 days from the signature date.

By entering my first and last name in the following box, I hereby certify that the foregoing information furnished is true and correct.

Enter your first and last name (See above, Required)

Provider's Signature:
Date: