The individual authorizes affiliated entities to share information pertaining to the individual ’ s clinical competence , professional conduct , and health . This information and documentation may be shared at any time , including , but not limited to , any initial evaluation of an individual ’ s qualifications , any periodic reassessment of those qualifications , or when a question is raised about the individual .
( f ) Authorization to Obtain Information from Third Parties :
The individual authorizes the Hospital , Medical Staff Leaders , and their representatives to consult with any third party who may have information relating to the individual ’ s professional competence or conduct or any other matter relating to their qualifications for initial or continued appointment , and to obtain communications , reports , records , and other documents of third parties that may be relevant to such questions . The individual also specifically authorizes third parties to release this information to the Hospital and its authorized representatives upon request .
( g ) Authorization to Disclose Information to Third Parties :
The individual authorizes the Hospital , Medical Staff Leaders , and their representatives , to disclose information to other hospitals , health care facilities , managed care organizations , government regulatory and licensure boards or agencies , and their representatives to assist them in evaluating the individual ’ s qualifications .
( h ) Authorization for Criminal Background Check :
The individual agrees to sign consent forms to permit a consumer reporting agency to conduct a criminal background check and report the results to the Hospital .
4877-0873-6192 , v . 3 14