Form 0917-0009 Conditions of Application and Release

Form Approved
OMB No. 0917-0009
Exp. Date XX/XX/20XX

Indian Health Service (IHS) Conditions of Application and Release
A. Conditions of Application
In return for my application being considered and processed, and as a condition of my continued appointment
if granted, I agree to be legally bound by the following terms and conditions:
1. It is my responsibility to produce adequate, accurate information so that my application can be properly
evaluated. In addition to the information provided in this application, I will respond to the Indian Health
Service (IHS) with any additional information requested regarding my application in order to facilitate the
release of relevant records and/or documents for the purpose of credentialing and privileging at IHS. My
failure to respond and provide any requested information within the time specified in the local medical staff
governance documents will deem my application incomplete and ineligible for processing. If there is no time
specified in the local medical staff governance documents I will provide the information within 30 calendar
days.
2. I will report within 15 calendar days to IHS any changes in the information I provide in my application,
including but not limited to: changes in licensure status, Drug Enforcement Administration or state
authorization to prescribe controlled substances; changes in medical staff appointment or clinical privileges
at another hospital or health care facility because of issues related to clinical competency or professional
misconduct; an arrest, charge, indictment, conviction, or a plea of guilty or no contest in any criminal matter
(other than a misdemeanor traffic citation), including driving under the influence (“DUI”); exclusion or
preclusion from participation in Medicare/Medicaid or any other federal health care program or the
imposition of any sanctions; any changes in my ability to safely and competently exercise clinical privileges or
perform the duties and responsibilities of appointment because of health status issues.
3. I will make myself available to answer questions regarding this application.
4. Consistent with my medical staff category assignment, I will accept all applicable committee appointments,
emergency call obligations, and such other reasonable Medical Staff duties and responsibilities consistent
with the facility’s bylaws and policy and procedures as shall be assigned to me.
5. I will provide professional, timely, continuous, competent and safe care for all my patients treated within IHS,
which includes proficiency in medical documentation in the electronic health record for optimal provider
communication, demonstration of sound medical judgment and fulfillment of IHS financial and legal
responsibilities.
6. My appointment and continued clinical privileges at any IHS facility remains contingent upon my continued
demonstration of professional competence, cooperation, acceptable performance of all related
responsibilities, and other factors deemed relevant by IHS.
7. I have received and have had an opportunity to read the facility’s Medical Staff governance documents
(bylaws, rules and regulations, and policies (“governance documents provided to me and I will abide by the
governance documents in force during the time of my appointment and while carrying out my clinical
privileges.
8. All of the information I provided in this application is accurate and complete. Any intentional
misrepresentation, misstatement, or omission from my application shall be cause for IHS to cease review of
my application. For current IHS employees applying for reappointment, cessation of the processing of this
application may result in termination from IHS. I understand that all information submitted on or with this
form is subject to investigation and review by IHS. In the event that an appointment has been granted prior
to the discovery of such misrepresentation, misstatement, or omission, such discovery may be deemed to
constitute automatic relinquishment of my clinical privileges and medical staff appointment.
1 – IHS Conditions of Application and Release

B. Authorizations and Releases
The purpose for the disclosure is: To provide information to the IHS for credentialing and privileging.
Information obtained by or to be released to the IHS is for the purposes stated below and may not be used
for any other purposes. By submitting my information for the purpose of credentialing and privileging at an
IHS facility, I expressly accept the following conditions and intend to be legally bound by them:
1. Authorization to Obtain Information from Third Parties
I authorize the IHS to obtain information about my ability and fitness to provide clinical care to IHS patients
for the purpose of processing my credentialing and privileging application.
I authorize the following individuals and entities to release, disclose or provide information to the IHS: my
previous employer(s), current employer(s), educational institutions, State licensing boards, professional
liability insurance carriers, the American Medical Association, the Federation of State Medical Boards, and
other governmental entities, professional organizations, persons, agencies, corporations or installations
with which I have been professionally associated. I also authorize any other appropriate sources to whom
IHS may be referred to release, disclose or provide information to IHS for the purpose of credentialing and
privileging.
I understand that IHS will seek, among other things, information and copies of records or documents
necessary to verify information pertaining to my professional qualifications, education, training, work
experience, credentials, clinical competence, character, ethics, behavior and conduct, ability and fitness to
perform safely and competently, or any other matter reasonably having a bearing on my qualification for
initial and continued appointment and/or clinical privileges. This may include information concerning each
civil lawsuit, criminal action, or administrative claim brought against me; each disciplinary action under
consideration or taken; any open or previously concluded investigations; and any changes in the status of
my credentials or privileges, and all supporting documents related to the matters described.
I authorize the IHS to provide a completed copy of this form to individuals and entities listed above, as well
as additional information and personal identifiers from my application if needed for the purpose of
processing my application.

SIGNATURE OF INDIVIDUAL

DATE

Printed or Typed Name

DATE

PUBLIC BURDEN STATEMENT
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0917-0009.
The time required to complete this information collection is estimated to average less than 30 minutes per response,
including the time to review instructions, search existing data resources, gather the data needed, to review and complete
the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: Indian Health Service, OMS/DRPC, 5600 Fishers Lane, Rockville, MD 20857,
Attention: Information Collections Clearance Officer.

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PRIVACY ACT STATEMENT:
The Privacy Act of 1974, 5 United States Code (U.S.C.) 552a, requires that a Federal agency provide a notice to each
individual from whom it collects information.
1. AUTHORITY: We are authorized to collect the information on this form and any supporting documentation,
including social security numbers, under the Snyder Act (25 U.S.C. 13), the Indian Health Care Improvement Act
(25 U.S.C. 1601 et seq.), and the Indian Health Service Transfer Act (42 U.S.C. 2001-2004). Information collected
through the use of the credentialing & privileging forms is contained in the following System of Records: [09-170003], “Indian Health Service Medical Staff Credentials and Privileges Records.” The IHS’s system of records
notices can be found on the website of the Department of Health & Human Services (HHS) at
https://www.hhs.gov/foia/privacy/sorns/ihs-sorns.html.
2. PURPOSES AND USES: The requested information is intended to be used for the principal purposes of
credentialing and privileging. Additional information concerning the purposes can be found in the system of
records notice associated with this form (see HHS website address above).
3. ROUTINE USES: In addition to the disclosures authorized directly in the Privacy Act at 5 U.S.C. 552a, the IHS has
established routine uses under which the agency may disclose information from the system of records associated
with this form without the consent of the subject individual. A complete list of the routine uses can be found in
the system of records notice associated with this form (see HHS website address above).
4. EFFECTS OF NON-DISCLOSURE: See statement below concerning disclosure of your social security number.
Disclosure of the other information is voluntary; however, failure to provide this information may delay or make
impossible credentialing, privileging, or the proper application of Civil Service rules, regulations and IHS personnel
policies, and thus may prevent you from obtaining employment, employee benefits or other entitlements.
5. INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PUBLIC LAW 93-579
SECTION 7(b): Disclosure of your SSN (social security number) is mandatory to obtain the employment and related
benefits that you are seeking. Solicitation of the SSN is authorized under the provisions of Executive Order 9397,
dated November 22, 1943. The SSN is used as an identifier throughout your Federal career from the time of
application through retirement. It will be used primarily to identify your records. The SSN also will be used by
Federal agencies in connection with lawful requests for information about you from your former employers,
educational institutions, and financial or other organizations. The information gathered through the use of the
number will be used only as necessary in personnel administration processes carried out in accordance with
established regulations and published notices of systems of records. The SSN also will be used for the selection of
persons to be included in statistical studies of personnel employment matters. The use of the SSN is made
necessary because of the large number of present and former Federal employees and applicants who have
identical names and birth dates, and whose identities can only be distinguished by the SSN.

3 – IHS Conditions of Application and Release