Authorization and Release

I hereby authorize Concern EAP to consult with any educational institution, board, other licensing or certification entities, former employer or any other professional organization, including past and present malpractice and/or professional liability carriers, who may have information bearing on my professional competence, character, or ethical qualifications. Upon request by Concern EAP, I will obtain and provide to Concern EAP documentation and materials pertaining to my qualifications and/or competence, including, but not limited to, any disciplinary action, suspension, or felony. I hereby consent to the inspection by Concern EAP, or its representatives, of all documents that it determines to be material to this evaluation of my professional competence.

I hereby release from liability all individuals, institutions, and entities with which I have been or am associated, including but not limited to professional liability carriers, previous employers, clinics, hospitals, state licensing organizations, professional societies, and health plans to provide any relevant information requested by Concern EAP or its representatives. In the event that I am accepted for participation in Concern EAP Provider Network, I hereby consent to Concern EAP inspection of my client records relating to Concern EAP participants as necessary for its utilization, clinical quality programs, and complaint resolution processes. I understand and agree that the authorizations and releases given by me are irrevocable as long as I am an applicant for participation status with Concern EAP or am participating in Concern EAP Provider Network.

I further agree to notify Concern EAP in a timely manner (not to exceed 30 days) of any changes to the information requested on the initial application. I understand that Concern EAP does not discriminate on the basis of race, sex, age, sexual orientation, or national origin. I further acknowledge that I have completely read and fully understand this application, Authorization and Release. I hereby certify that all information contained in this Application and all of its attachments is complete, true and correct.

Lastly, I acknowledge that this authorization of release of information shall be effective upon the date of my signature and, furthermore shall remain in effect for the duration of my agreement with Concern EAP.