0917-0009 Conditions of Release

Form Approved OMB No. 0917-0009

Exp. Date XX/XX/20XX

Indian Health Service (IHS) Conditions of Application and Release

1. Conditions of Application

In return for my application being considered and processed, and as a condition of my continued appointment if granted, I agree to be legally bound by the following terms and conditions:

1. It is my responsibility to produce adequate, accurate information so that my application can be properly evaluated. In addition to the information provided in this application, I will respond to the Indian Health Service (IHS) with any additional information requested regarding my application in order to facilitate the release of relevant records and/or documents for the purpose of credentialing and privileging at IHS. My failure to respond and provide any requested information within the time specified in the local medical staff governance documents will deem my application incomplete and ineligible for processing. If there is no time specified in the local medical staff governance documents I will provide the information within 30 calendar days.

2. I will report within 15 calendar days to IHS any changes in the information I provide in my application, including but not limited to: changes in licensure status, Drug Enforcement Administration or state authorization to prescribe controlled substances; changes in medical staff appointment or clinical privileges at another hospital or health care facility because of issues related to clinical competency or professional misconduct; an arrest, charge, indictment, conviction, or a plea of guilty or no contest in any criminal matter (other than a misdemeanor traffic citation), including driving under the influence (“DUI”); exclusion or preclusion from participation in Medicare/Medicaid or any other federal health care program or the imposition of any sanctions; any changes in my ability to safely and competently exercise clinical privileges or perform the duties and responsibilities of appointment because of health status issues.

3. I will make myself available to answer questions regarding this application.

4. Consistent with my medical staff category assignment, I will accept all applicable committee appointments, emergency call obligations, and such other reasonable Medical Staff duties and responsibilities consistent with the facility’s bylaws and policy and procedures as shall be assigned to me.

5. I will provide professional, timely, continuous, competent and safe care for all my patients treated within IHS, which includes proficiency in medical documentation in the electronic health record for optimal provider communication, demonstration of sound medical judgment and fulfillment of IHS financial and legal responsibilities.

6. My appointment and continued clinical privileges at any IHS facility remains contingent upon my continued demonstration of professional competence, cooperation, acceptable performance of all related responsibilities, and other factors deemed relevant by IHS.

7. I have received and have had an opportunity to read the facility’s Medical Staff governance documents (bylaws, rules and regulations, and policies (“governance documents provided to me and I will abide by the governance documents in force during the time of my appointment and while carrying out my clinical privileges.

8. All of the information I provided in this application is accurate and complete. Any intentional misrepresentation, misstatement, or omission from my application shall be cause for IHS to cease review of my application. For current IHS employees applying for reappointment, cessation of the processing of this application may result in termination from IHS. I understand that all information submitted on or with this form is subject to investigation and review by IHS. In the event that an appointment has been granted prior to the discovery of such misrepresentation, misstatement, or omission, such discovery may be deemed to constitute automatic relinquishment of my clinical privileges and medical staff appointment.

B. Authorizations and Releases

The purpose for the disclosure is: To provide information to the IHS for credentialing and privileging.

Information obtained by or to be released to the IHS is for the purposes stated below and may not be used for any other purposes. By submitting my information for the purpose of credentialing and privileging at an IHS facility, I expressly accept the following conditions and intend to be legally bound by them:

1. Authorization to Obtain Information from Third Parties

I authorize the IHS to obtain information about my ability and fitness to provide clinical care to IHS patients for the purpose of processing my credentialing and privileging application.

I authorize the following individuals and entities to release, disclose or provide information to the IHS: my previous employer(s), current employer(s), educational institutions, State licensing boards, professional liability insurance carriers, the American Medical Association, the Federation of State Medical Boards, and other governmental entities, professional organizations, persons, agencies, corporations or installations with which I have been professionally associated. I also authorize any other appropriate sources to whom IHS may be referred to release, disclose or provide information to IHS for the purpose of credentialing and privileging.

I understand that IHS will seek, among other things, information and copies of records or documents necessary to verify information pertaining to my professional qualifications, education, training, work experience, credentials, clinical competence, character, ethics, behavior and conduct, ability and fitness to perform safely and competently, or any other matter reasonably having a bearing on my qualification for initial and continued appointment and/or clinical privileges. This may include information concerning each civil lawsuit, criminal action, or administrative claim brought against me; each disciplinary action under consideration or taken; any open or previously concluded investigations; and any changes in the status of my credentials or privileges, and all supporting documents related to the matters described.

I authorize the IHS to provide a completed copy of this form to individuals and entities listed above, as well as additional information and personal identifiers from my application if needed for the purpose of

processing my application.

SIGNATURE OF INDIVIDUAL	DATE
Printed or Typed Name	DATE

PUBLIC BURDEN STATEMENT

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0917-0009. The time required to complete this information collection is estimated to average less than 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Indian Health Service, OMS/DRPC, 5600 Fishers Lane, Rockville, MD 20857, Attention: Information Collections Clearance Officer.

PRIVACY ACT STATEMENT:

The Privacy Act of 1974, 5 United States Code (U.S.C.) 552a, requires that a Federal agency provide a notice to each individual from whom it collects information.

1. AUTHORITY: We are authorized to collect the information on this form and any supporting documentation, including social security numbers, under the Snyder Act (25 U.S.C. 13), the Indian Health Care Improvement Act (25 U.S.C. 1601 et seq.), and the Indian Health Service Transfer Act (42 U.S.C. 2001-2004). Information collected through the use of the credentialing & privileging forms is contained in the following System of Records: [09-17- 0003], “Indian Health Service Medical Staff Credentials and Privileges Records.” The IHS’s system of records notices can be found on the website of the Department of Health & Human Services (HHS) at https://www.hhs.gov/foia/privacy/sorns/ihs-sorns.html.

2. PURPOSES AND USES: The requested information is intended to be used for the principal purposes of credentialing and privileging. Additional information concerning the purposes can be found in the system of records notice associated with this form (see HHS website address above).

3. ROUTINE USES: In addition to the disclosures authorized directly in the Privacy Act at 5 U.S.C. 552a, the IHS has established routine uses under which the agency may disclose information from the system of records associated with this form without the consent of the subject individual. A complete list of the routine uses can be found in the system of records notice associated with this form (see HHS website address above).

4. EFFECTS OF NON-DISCLOSURE: See statement below concerning disclosure of your social security number. Disclosure of the other information is voluntary; however, failure to provide this information may delay or make impossible credentialing, privileging, or the proper application of Civil Service rules, regulations and IHS personnel policies, and thus may prevent you from obtaining employment, employee benefits or other entitlements.

5. INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PUBLIC LAW 93-579

SECTION 7(b): Disclosure of your SSN (social security number) is mandatory to obtain the employment and related benefits that you are seeking. Solicitation of the SSN is authorized under the provisions of Executive Order 9397, dated November 22, 1943. The SSN is used as an identifier throughout your Federal career from the time of application through retirement. It will be used primarily to identify your records. The SSN also will be used by Federal agencies in connection with lawful requests for information about you from your former employers, educational institutions, and financial or other organizations. The information gathered through the use of the number will be used only as necessary in personnel administration processes carried out in accordance with established regulations and published notices of systems of records. The SSN also will be used for the selection of persons to be included in statistical studies of personnel employment matters. The use of the SSN is made necessary because of the large number of present and former Federal employees and applicants who have identical names and birth dates, and whose identities can only be distinguished by the SSN.

1 – IHS Conditions of Application and Release