• I understand that it is my responsibility to provide evidence of my competence and qualifications

  • 2. I hereby authorize Right Path Behavioral Health to consult with administrators and the member of medical/clinical staff of hospitals, organization, purcahsers of service and obtain information relevent to inforamtion submitted/ obtain from this credentialing Application. Right Path Behavioral Health is likewise authorized to consult with any other person, firm, or entity that may have information hearing on my professional competency, chracter and ethical qualifications. The employee has the right to be notified of any erroneous information obtained, and correct any misinformation.

  • 3. I hereby agree to comply with the policies and procedures of Right Path Behavioral Health, to include: Employee Ethics case record keeping requirements, ulilization management, biling and quality/performance expectations.

  • 4. Thereby release from liability all represntatives of Right Path Behavioral Health for acts performed in connection with the evaluation of my application, my credentials and qualification. I further rlease from liabilty any and all individuals and organization that provide information to Right Path Behavioral Health concerning any professional competence, and qualification in connection with this application. I hereby consent to the release of such information as may be requested.

  • 5. I attest that the information in this application is complete and correct. I acknowledge that this consent and release Form will be valid untill revoked by me, and that a photocopy or fax will serve as an original.