Native Village of Eyak- Ilanka Community Health Center Employment Application Page 8 of 8
The Native Village of Eyak
Ilanka Community Health Center
Provider Applicant’s Statement of Understanding, Authorization, and Liability Release
In connection with applying for employment, and/or clinic privileges with the Ilanka Community Health
Center, I hereby authorize the Ilanka Clinic, it’s medical staff, representatives, employees, and agents to
consult the following entities and individuals:
• Current and former representatives and employees of health care organizations, providers or
entities with which I have been associated on a professional basis, including supervisors or
collaborative physicians and;
• Individuals or organizations, including past and present malpractice carriers, employers, and state
regulatory authorities, who may have information bearing on my professional competence,
character, and ethical qualifications.
I authorize the above entities and individuals to disclose fully any and all information or records about me
that may be relevant to the research, references, and information requests of the Ilanka Community Health
Center. I release any and all individuals and entities who provide information to the Ilanka Community
Health Center in response to this authorization, or who otherwise provide information concerning my
professional competence, ethics, character, or other qualifications, from any and all claims, causes of
action, or liability whatsoever.
I also authorize the Ilanka Community Health Center to inspect or copy all records and documents,
including medical records at other hospitals or healthcare organizations, that may be material to its
evaluation of my professional qualifications and competence to carry out the clinical privileges requested,
and my moral and ethical qualifications for staff membership.
I hereby consent to the release of any information by the Ilanka Community Health Center that may be
relevant to or that may be disclosed regarding seeking information and references concerning my
licensure, competence, ethics, character, or other qualifications.
I fully release the Ilanka Community Health Center, its medical staff, representatives, employees and
agents from all claims or liability for acts and omissions, including communications, that occur regarding
evaluating my application, credentials, qualifications, character, and suitability.
I understand and assume the duty of responsibility of informing the Ilanka Community Health Center, in a
timely manner, of subsequent changes in any information provided on or relative to this application.
Applicant Printed Name
Applicant Signature Date