Free VA Form 10-0459 - Credentialing Release of Information Authorization - Federal

File Size: 378.6 kB
Pages: 1
Date: January 24, 2008
File Format: PDF
State: Federal
Category: Veterans Forms
Word Count: 234 Words, 1,592 Characters
Page Size: Letter (8 1/2" x 11")

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Credentialing Release of Information Authorization

In order for the

Insert Facility Name

to access and verify my educational

background, professional qualifications and suitability for appointment, I hereby authorize the to make inquiries and consult with all persons, places of
Insert Facility Name

employment, education, malpractice carriers, State licensing boards, or other similar government and non-governmental entities who have or may have information bearing on my moral, ethical and professional qualifications and competence to carry out the privileges I have requested. I consent to the release of information about my ability and fitness for Federal appointment and I authorize release of such information and copies of related records and/or documents to VA officials to include not only the requested information for verification but information concerning each lawsuit, civil action, or other claim brought against me for malpractice or negligence; each disciplinary action under consideration or taken; any open or previously concluded investigations; and any changes in the status of a credential and all supporting documentation related to the information provided. I authorize the VA to disclose to such persons, employers, institutions, boards or agencies identifying and other information about me sufficient to enable the VA to make such inquiries. I release from liability all those who provide information to the Department of Veterans Affairs in good faith and without malice in response to such inquiries.
Full Name Date