I acknowledge that Luna Care, Inc. (and its state-specific affiliates) has been engaged to provide certain credentialing services from time to time on an ongoing basis in connection with my partnership. I understand that Luna must collect information from me and from third parties and share all or part of that information. Such information may include, for example, my licensure, relevant education, training and experience, clinical competence, character and ethics. I understand that with respect to the credentialing application process, the information will be evaluated along with such other criteria Luna may consider for determining my initial and ongoing eligibility to provide physical therapy services.
Agreement to Provide Information
I agree to provide on a timely basis as requested by Luna sufficient and accurate information as deemed necessary or appropriate by Luna for the completion, submittal and support of my credentialing applications.
Authorization of Investigation Concerning Application
I authorize Luna and their respective employees to collect, hold, and investigate information, which includes both oral and written statements, records, and documents, concerning or to be included in my credentialing applications. I agree to allow any the inspection and copy of all records and documents relating to my credentialing applications and to disclose any such information as necessary.
Authorization of Third-Party Sources to Release Information
I authorize any third party, including but not limited to, individuals, agencies, groups responsible for credentials verification, corporations, companies, employers, former employers, licencing agencies, insurance companies, education and other institutions, medical credentialing and accreditation agencies, professional medical societies, state medical boards, the National Practitioner Data Bank, promptly upon the request to release, including otherwise privileged or confidential information, concerning my professional qualifications, credentials education, training, clinical competence, quality assurance and utilization data, character, ethics, behaviors, or other matter having a bearing on my qualification for credentialing with Luna. I authorize my current and past professional liability carrier(s) to release to Luna my history of claims that have been made and/or are currently pending against me. I specifically waive written notice from any entities and individuals who provide information base upon this Authorization, Attestation, and Release.
Release from Liability
I release from all liability and hold harmless Luna and any entity responding to a request for information as authorized hereunder, and any other third party, and their respective wonder, managers, directors, officers, employees, agents and representatives, for their acts performed in good faith and without malice unless such acts are due to the gross negligence or willful misconduct of Luna or other third party in connect with the gathering, holding, use, sharing and interpretation of, and reliance upon, information which is the subject of this Authorization, Attestation, and Release. This release shall be in addition to, and in no way shall limit, any other applicable immunities provided by law for credentialing activities.
I certify that all information provided by me in connection with my credentialing application is current, true, correct, accurate and complete to the best of my knowledge and belief, and is furnished in good faith. I will notify Luna within 10 days of any material changed to my information (including any changes/challenges to license, insurance, malpractice claims, NPDB reports, discipline, criminal convictions, etc.) I have provided in connection with my credentialing application or authorized to be release in connection with the credentialing application.
I further acknowledge that I have read and understand the forgoing Authorization, Attestation and Release. I understand and agree that a facsimile signature photocopy of the Authorization, Attestation and Release shall be as effective as the original.