LDP RDH Application 01012020 rev. Page | 3
Information Release / Acknowledgments:
I authorize VerifPoint/CreDENTIALs or any LIBERTY Dental Plan contracted (“CVO”), to consult with
professional liability carriers and other persons or entities to obtain information concerning my professional
qualifications, including competence, ethics and other qualifications.
I hereby consent to the disclosure, inspection and copying of information and documents relating to my
credentials, qualifications and performance (under “Credentialing Information”) by and between LIBERTY
Dental Plan and other Healthcare Organizations (e.g. hospital medical staff, medical groups, independent
practice associations (IPA’s), health plans, health maintenance organizations (HMO’s), preferred provider
organizations (PPO’s), other health delivery systems or entities, medical societies, professional associations,
medical school faculty positions, training programs, professional liability insurance companies (with respect
to certification of coverage and claims history), licensing authorities, businesses and individuals acting as
their agents (collectively, “HealthCare Organizations), for the purpose of evaluating this application and re-
credentialing application regarding my professional training, experience, character, conduct, judgment,
ethics, records and ability to work with others. In this regard, the utmost care shall be taken to safeguard
the privacy of patients and the confidentiality of patients’ records and to protect credentialing information
from being further disclosed.
I am informed and acknowledge that federal and state laws provide immunity protections to certain
individuals and entities for their acts and/or communications in connection with evaluation the
qualifications of healthcare providers. I hereby release all persons and entities, including LIBERTY Dental
Plan and its agent(s), engaged in quality assessment, peer review and credentialing on behalf of LIBERTY
Dental Plan, from an liability they might incur for their acts and/or communications in connection with
evaluation of my qualifications for participation with LIBERTY Dental Plan, to the extent that those acts
and/or communications are protected by state and federal law.
I, the undersigned, hereby certify that the information requested by the CVO is truthful, correct and
complete in all respects and I further understand that the intentional submission of false or misleading
information or the withholding of relevant information is grounds for termination as a participating provider
with the affiliated organization contracted with the CVO. The undersigned hereby agrees to notify the CVO
of any changes in the above information.
I understand that if LIBERTY Dental Plan denies my application or otherwise takes action that is adverse to
my request for participation, LIBERTY Dental Plan and/or its Representatives may be obligated, under
applicable law, to report such action to the National Practitioner Data Bank and/or other licensing or
accreditation agencies.
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