In consideration of the PNW Transplant Society processing my application for membership, I grant permission and consent for you to obtain from all hospital affiliations, information regarding staff privileges, and actions relating thereto; and all information from former medical society affiliations, specialty organizations, and other organizations providing medical training including internship and residencies.
I agree to furnish the Society with all information relative to any claim or action filed against me for malpractice, and I authorize and consent for you to obtain from my insurance malpractice carrier any and all information regarding insurance coverage, premiums, claims, and actions against me.
I further authorize disclosure of information generally considered to be reliable which has a bearing on my professional competence, character, and ethical qualifications to all hospitals, and medical licensing or discipline boards who request such information.
I hereby release, and hold harmless from any liability or loss, the PNW Transplant Society, its officers, agents, employees, and members, for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and hereby release from any liability any and all individuals and organizations, who, in good faith and without malice, provide information to the Society, or to its authorized representatives, concerning my professional competence, ethical conduct, character and other qualifications for membership.
I further release from liability the Society, its officers, agents, employees, and members for the delivery of information to any third party as authorized herein, provided such delivery occurs prior to the acknowledged receipt, in the office of the Society, of a written notice or revocation of this release.
I hereby agree to abide by the By-Laws and the Principles of Medical ethics of the Society and agree upon approval of membership, that my membership in the Society shall be conditional upon continued compliance of the aforementioned; and I further agree to recognize and abide by the interpretation thereof by the authorized officers of the Society, reserving all rights of appeal as set forth in the By-Laws of this Society.
I HEREBY AFFIRM AND REPRESENT THAT ALL STATEMENTS, ANSWERS, AND INFORMATION CONTAINED IN THIS APPLICATION ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
I declare under penalty of perjury under the laws of the State of Washington that all statements, answer and information contained in this application are true and correct.