ࡱ> BDA Ebjbj H0||8"><z(( $SX-=(pcw/@e<]>.<Z'@g4l.]| :  AUTHORIZATION AND RELEASE FROM LIABILITY I am an applicant for appointment to the University Hospitals Research Staff (hereinafter Participation) at University Hospitals Case Medical Center (hereinafter Entity). I understand and acknowledge that it is my responsibility to provide all information requested by Entity upon which a proper evaluation can be undertaken, including but not limited to education level, current employment, health status, character, ethics, and any other criteria adopted by the Entity for Participation, and for resolving any discrepancies or doubts about such information. I further acknowledge that I am responsible for knowing the contents of the applicable bylaws, rules, policies, corporate code of conduct, and requirements of the Entity and its professional staff or network, and agree to be bound by them in the application process and if granted Participation. I understand and acknowledge that Participation is a privilege, and that I am not automatically entitled to Participation simply by virtue of my academic background, professional training, or membership in a particular institution or professional organization. I understand and agree that I have no right to Participation, that Entity may terminate or alter the terms of my Participation at any time for any reason or no reason, and that neither my appointment to the staff nor my execution of this agreement creates any contractual right, whether express or implied. I further understand that Participation does not constitute approval of clinical privileges, and that my Participation does not permit me to provide clinical treatment of patients in any manner. By submitting this Application, I agree to such investigation and to the disciplinary reporting and information exchange activities of the Entity and its Agents as follows: 1. Authorization of Investigation and Release of Information Concerning Application for Participation. I authorize Entity and its Agents to consult with any third party who may have information bearing on my professional qualifications, credentials, competence, character, health status, ethics, behavior, or any other matter reasonably having a bearing on my qualifications for Participation and authorize such third parties to release such information to the Entity and its Agents. 2. Release from Liability. I hereby further release from liability the Entity and its Agents, state licensing boards, health care organizations, academic institutions, consultants, any staff thereof, and all individuals, institutions, and entities providing information in accordance with this authorization, for their acts performed in good faith and without malice in connection with the gathering, evaluating, and release and exchange of information as consented to above. This release shall be in addition to any other applicable immunities provided by law for peer review activities. I understand and agree that this Authorization and Release is irrevocable for any period during which I am an applicant for Participation at the Entity, or I am a member of Entitys Research Staff. I agree to execute another consent as required by law, regulation, or Entity accreditation standards. All information submitted by me in this application is complete and true to my best knowledge and belief. I understand and agree that any material misstatements in, or omissions from this application constitute cause for denial of or revocation of Participation. I understand and acknowledge that the Entity shall be solely responsible for all decisions concerning the granting of Participation. I further acknowledge that I have read and understand the foregoing Authorization and Release. I further acknowledge that I have received the UH Code of Conduct (  HYPERLINK "http://www.uhhospitals.org/aboutuh/missionvision/tabid/1806/codeofconduct.aspx" http://www.uhhospitals.org/aboutuh/missionvision/tabid/1806/codeofconduct.aspx). I have read, understood and agree to abide by the UH Code of Conduct. A copy of this original document as signed by me shall have all the same force and effect as the signed original. / /  FORMTEXT       _ Date Signed Applicants Printed Name Applicant's Signature ( MM/DD/YYYY)     Research Staff Application for Initial Appointment Page  PAGE 2 of  NUMPAGES 5 Last Revised Date 8/29/2011 +Dk   O U \ s = >%>x3567ϻϭϻϙϻϻϻhW#h0JOJQJaJ'jhW#hOJQJUaJjhOJQJUaJh6"hOJQJaJ h6"hhOJQJaJhFhOJQJaJhFh5OJQJaJh5OJQJaJ6,-U@$ VxP X(`0h8 "$'x*d@&]^a$gd?$ VP X( ` 0h8p@ x!"%(h d]h^ a$gd*$ ) 8p@ x!"%(h d@&]h^ a$gd @@@@?$ VxP X(`0h8 "$'x*d]^a$gd@$ VxP X(`0h8 "$'x*d@&]^a$gd?$ VxP X(`0h8 "$'x*d]^a$gd:;!"rs~?~?$ VxP X(`0h8 !"'x*d]^a$gdA$ Sx*P X(`0h8 !"'x**d]^*`a$gd?$ VxP X(`0h8 "$'x*d]^a$gd34<$ VxP X(`0h8 "$'x*d@&C$Eƀt&]^a$gd?$ VxP X(`0h8 "$'x*d]^a$gd8@@@?$ VxP X(`0h8 "$'x*d]^a$gd@$ VxP X(`0h8 "$'x*d@&]^a$gd?$ VxP X(`0h8 "$'x*d]^a$gd  7?GYr޸Ψ鐈zoh 5CJOJQJh CJOJQJhtAjhtAUh hCJ OJQJhOJQJaJjhN>*CJOJQJU*jhSoh>*CJOJQJUjh>*CJOJQJUh>*CJOJQJhCJOJQJhFhOJQJaJ&$ HZd]^Za$gd  Hd]^`gd $ Hda$gd $ *HV]^Va$gd ($ ) `0h8 "$'x*d]^a$gd !"#$%ABCDEѶѶ¡܅htAhSoh CJaJhSoh 0JCJaJh 0JCJh 0JCJmHnHujh 0JCJUjhSoh 0JCJUhSoh 0JCJh h OJQJh >*CJOJQJh 5>*CJOJQJ%BCDE]gd $]a$gd F 00P&P:pBP/ =!"#@$% DpDyK Ohttp://www.uhhospitals.org/aboutuh/missionvision/tabid/1806/codeofconduct.aspxyK http://www.uhhospitals.org/aboutuh/missionvision/tabid/1806/codeofconduct.aspxyX;H,]ą'cvDText55j 666666666vvvvvvvvv66666>66666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmH nH sH tH P`P Normal1$#CJOJPJQJ_HhmH sH tH DA`D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List 0U@0  Hyperlink>*B*4 @4 Footer  !JJ  Footer CharCJOJPJQJ^JaJh.)@!.  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