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

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

Signature

VA FORM JAN 2008

10-0459