Prospective Physician Information

Personal Information

Please complete the requested information in order to facilitate plans for your on-site interview.

References

Please list three (3) professional references.

Background Information

Archbold Regional Health System Release of Liability and Practitioner’s Statement

  • Signify my willingness to appear for interviews in regard to my application.
  • Authorize hospital representatives to consult with others who have been associated with me and/or who may have information bearing on my competence and qualifications.
  • Consent to hospital representatives’ inspection of all records and documents that may be material to an evaluation of my professional qualifications and competence to carry out the clinical privileges I request, of my physical and mental health status, and of my professional ethical qualifications.
  • Release from any liability all hospital representatives for their acts performed in good faith and without malice in connection with evaluation of me and my credentials.
  • Release from any liability all individuals and organizations who provide information, including otherwise privileged or confidential information, to hospital representatives in good faith and without malice concerning my competence, professional ethics, character, physical and mental health, emotional stability, and other qualifications for staff appointment and clinical privileges.
  • Authorize and consent to hospital representatives providing other hospitals, medical associations, licensing boards, and other organizations concerned with provider performace and the quality and efficiency of patient care with any information relevant to such matters that the hospital may have concerning me, and release hospital representatives from liability for so doing, provided that such furnishing of information is done in good faith and without malice.