I confirm that all of the information provided in or attached to this application is accurate and complete. I understand and agree that any misrepresentation, misstatement, or omission from this application, whether intentional or not, shall constitute cause for the immediate cessation of the processing of the application and no further processing shall occur. 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. In either situation, I am not entitled to any hearing or appeal rights that are contained in the Credentialing Policy.

I authorize the Hospital, its Nursing staff, and their authorized representatives (i) to consult with any third party who may have information bearing on my professional qualifications, credentials, clinical competence, character, ability to perform safely and competently, ethics, behaviour, or any other matter reasonably having a bearing on my qualifications for initial and continued appointments to the medical staff, and (ii) to obtain any and all communications, reports, records, statements, documents, recommendations or disclosures of said third parties that may be relevant to such questions. In addition, I specifically authorize these third parties to release the information to the Hospital, its medical staff, and their authorized representatives upon request.