The information submitted in this form is 100% confidential.&nbsp;

Welcome to Four Wind Staffing's Standard Authorization Form (SAF).

Section 1 - Individual Information

What is your full name?

If applicable, what is your prior full name?

When did your current full name become effective?

What is your email address?

What is your mobile phone number?

What is your home phone number?

What is your current home address?

What is your date of birth?

What is your gender?

What is your drivers license number?

What state was your divers license issued in?

What is the expiration date of your drivers license?

What is your country of birth?

What is your state of birth?

What is your city of birth?

What is your social security number?

(All current or past licensure information.)

Section 2 - Professional Licensure

What are your credentials?

If applicable, what is your National Provider Identifier (NPI) number?

What is your current medical license number?

For your current license number, which state are you licensed for?

For your current license number, when was the license issued?

For your current license number, when does the license expire?

Do you have any other currently or previously active medical licenses?

What is your previous medical license number?

For your previous license number, which state were you licensed for?

For your previous license number, when was the license issued?

For your previous license number, when does the license expire?

Do you have a Federal Drug Enforcement Administration (DEA) license?

What is your current Federal Drug Enforcement Administration (DEA) license number?

What state is your current Federal Drug Enforcement Administration (DEA) license active in?

What is the zip code of your current Federal Drug Enforcement Administration (DEA) license active in?

When was your current Federal Drug Enforcement Administration (DEA) license issued?

When does your current Federal Drug Enforcement Administration (DEA) license expire?

Do you have any other currently or previously active Federal Drug Enforcement Administration (DEA) licenses?

What is your previous Federal Drug Enforcement Administration (DEA) license number?

What state is your previous Federal Drug Enforcement Administration (DEA) licensed in?

What is the zip code of your previous Federal Drug Enforcement Administration (DEA) license?

When was your previous Federal Drug Enforcement Administration (DEA) license issued?

What's your previous Federal Drug Enforcement Administration (DEA) license expiration?

(All addresses you have lived in the past 7 years.)

Section 3 - Background Check

What is your current address?

Have you lived in any different address in the past 7 years?

What is your other past address?

Have you lived in any other different address in the past 7 years?

(One reference of three must be a current supervisor or medical director.)

Section 4 - Professional Reference

What is the full name of your first professional reference?

What are the credentials of the&nbsp;first professional reference?

What is the phone number of your first professional reference?

What is the email of your first professional reference?

What is the full name of your second professional reference?

What are the credentials of your second professional reference?

What is the phone number of your second professional reference?

What is the email of your second professional reference?

What is the full name of your third professional reference?

What are the credentials of your third professional reference?

What is the phone number of your third professional reference?

What is the email of your third professional reference?

(For each questions if you select yes, you will be asked to provide additional information.)

Section 6 - Professional Practice Questions

Have you ever been fired from any job for any reason, did you quit after being told
that you would be fired, or did you leave any job by mutual agreement because of
specific problems?

Please provide your explanation for the previous question.

Has any of your state licensure or Federal DEA ever had any disciplinary actions,
investigations, denied, restricted, limited, suspended, revoked, canceled, or
involuntarily withdrawn?

Have you ever been reprimanded, censured, excluded, suspended, and/or
disqualified from participating in or voluntarily withdrawn, to avoid an investigation
by Medicare, Medicaid, Tri-Care, and/or any other governmental health related
programs?

Has any information pertaining to you, including malpractice judgments and/or
disciplinary action ever been reported to the National Practitioner Data Bank or any
other practitioner data bank?

Have you ever had a claim for professional negligence asserted against you?

Have you ever withdrawn from or been suspended, dismissed, or expelled from a
professional school or postgraduate training program, or has any third party ever
attempted to have you withdrawn, suspended, dismissed, or expelled from a
professional school or postgraduate training program?

Have you been charged with or convicted of a crime in any state or country?

Have you been diagnosed with chemical dependency (i.e., alcohol, illegal drugs,
prescriptive drugs, etc.)?

Do you have any known physical or mental impairments that would impact your ability to
perform the position requested?

Are you delinquent on any Federal debt? (Includes delinquencies arising from
Federal taxes, loans, etc.)

Section 7 -&nbsp;Legality and Consent

I understand and agree that, as part of the credentialing application process for participation, membership,
and/or clinical privileges (hereinafter referred to as “participation”) at or with each of the federal or
state agencies, tribal entities, or healthcare facilities with which Four Winds Staffing LLC has or will
have a staffing relationship (hereinafter each referred to as the “Entity”) and any of the Entity’s
affiliated entities, I am required to provide sufficient and accurate information for a proper evaluation of
my current licensure, relevant training and/or experience, clinical competence, health status, vaccination
status, character, ethics, and any other criteria used by the Entity for determining initial and ongoing
eligibility for Participation. Each Entity and its representatives, employees, and agent(s) are obligated to
keep the information obtained relating to the application process confidential except where disclosure is
otherwise permitted or required by law.
I acknowledge that each Entity has its own criteria for acceptance, and I may be accepted or rejected
by each independently. I further acknowledge and understand that my cooperation in obtaining information
and my consent to the release of information do not guarantee that any Entity will grant me clinical
privileges or contract with me directly or indirectly via Four Winds Staffing LLC as a provider of services.
I understand that my application for Participation with the Entity is not an application for employment
with the Entity and that acceptance of my application by the Entity will not result in my employment
by the Entity.
For Hospital Credentialing. I consent to appear for an interview with the credentials committee, medical
staff executive committee, or other representatives of the medical staff, hospital administration, or the
governing board, if required or requested. As a medical staff member, I pledge to provide continuous
care for my patients. I have been informed of existing hospital bylaws, rules, and regulations, and
policies regarding the application process, and I agree that as a medical staff member, I will be bound by
them.
Authorization of Investigation Concerning Application for Participation. I authorize the following
individuals including, without limitation, Four Winds Staffing LLC, the Entity, and its/their representatives,
employees, and/or designated agent(s); Four Winds Staffing LLC and the Entity’s affiliated entities and&nbsp;their representatives, employees, and/or designated agents; and Four Winds Staffing’s, and the Entity’s
designated professional credentials verification organization(s) (collectively referred to as “Agents”) to
investigate information, which includes both oral and written statements, records, and documents,
concerning my application for Participation. I agree to allow the Entity and its/their Agent(s) to inspect and
copy all records and documents relating to such an investigation including, but not limited to, records and
documents relating to investigations conducted by Four Winds Staffing LLC. I expressly authorize Four
Winds Staffing LLC to release and otherwise disclose any and all of the records and documents of its
credentialing investigation including, but not limited to, information provided by me and from third-party
sources (e.g., licensing verification, employment history, NPDB queries, criminal background checks,
drug screens, COVID-19 test results, proof of vaccination (including COVID-19 vaccination status and
proof)), with each and every Entity and/or its Agent(s) without my separate written approval for the
release or disclosure of such release or disclosure of such information.
Authorization of Third-Party Sources to Release Information Concerning Application for
Participation. I authorize any third party, including, but not limited to, individuals, agencies, medical
groups responsible for credentials verification, corporations, companies, employers, former employers,
hospitals, health plans, health maintenance organizations, managed care organizations, law enforcement or
licensing agencies, insurance companies, educational and other institutions, military services, medical
credentialing and accreditation agencies, professional medical societies, the Federation of State Medical
Boards, the National Practitioner Data Bank, and the Health Care Integrity and Protection Data Bank, to
release to Four Winds Staffing LLC, the Entity, and/or its Agent(s), information, including otherwise
privileged or confidential information, concerning my professional qualifications, credentials, clinical
competence, quality assurance and utilization data, character, mental condition, physical condition,
COVID-19 test results, vaccination status, vaccination results, alcohol or chemical dependency diagnosis
and treatment, ethics, behavior, or any other matter reasonably having a bearing on my qualifications
for Participation in, or with, the Entity. I authorize my current and past professional liability carrier(s)
to release my history of claims that have been made and/or are currently pending against me. I specifically
waive written notice from any entities and individuals who provide information based upon this
Authorization, Attestation, and Release.
Authorization of Release and Exchange of Disciplinary Information. I hereby further authorize
any third party at which I currently have Participation or had Participation and/or each third party’s agents
to release “Disciplinary Information,” as defined below, to Four Winds Staffing LLC, the Entity,
and/or its Agent(s). I hereby further authorize Four Winds Staffing LLC and the Agent(s) to release
Disciplinary Information about any disciplinary action taken against me to the Entities at which I have
or am requesting to have Participation, and as may be otherwise required by law. As used herein,
“Disciplinary Information” means information concerning (i) any action taken by such health care
organizations, their administrators, or their medical or other committees to revoke, deny, suspend, restrict,
or condition my Participation or impose a corrective action plan; (ii) any other disciplinary action
involving me, including, but not limited to, discipline in the employment context; or (iii) my resignation
prior to the conclusion of any disciplinary proceedings or prior to the commencement of formal charges,
but after I had (or have) knowledge that such formal charges were being (or are being) contemplated and/or
were (or are) in preparation.&nbsp;Release from Liability. I release from all liability and hold harmless Four Winds Staffing LLC, each
Entity, its/their Agent(s), and any and all other third party(ies) for their acts performed in good faith
and without malice unless such acts are due to the gross negligence or willful misconduct of Four
Winds Staffing LLC, the Entity, its/their Agent(s), or other third party(ies) in connection with the gathering,
release, and exchange of, and reliance upon, information used in accordance with this Authorization,
Attestation, and Release. I further agree not to sue Four Winds Staffing LLC, any Entity, its/their
Agent(s), or any other third party(ies) for their acts, defamation, or any other claims based on statements
made in good faith and without malice or misconduct of Four Winds Staffing LLC, the Entity,
its/their Agent(s), or third party(ies) in connection with the credentialing process. This release shall be
in addition to, and in no way shall limit, any other applicable immunities provided by law for peer review
and credentialing activities. In this Authorization, Attestation, and Release, all references to Four Winds
Staffing LLC, the Entity, its/their Agent(s), and/or other third party(ies) include their respective
employees, directors, boards, shareholders, members, managers, officers, advisors, counsel, and agents.
Four Winds Staffing LLC, the Entity, and/or any of its/their affiliates or agents retains the right to allow
access to the application information for purposes of a credentialing audit to customers and/or their
auditors to the extent required in connection with an audit of the credentialing processes and provided
that the customer and/or their auditor executes an appropriate confidentiality agreement. I understand and
agree that this Authorization, Attestation, and Release is irrevocable for any period during which I am
contracted with Four Winds Staffing LLC, an applicant for Participation at an Entity, a member of an
Entity’s medical or health care staff, and/or a participating provider of an Entity. I agree to execute another
form of consent if law or regulation limits the application of this irrevocable authorization. I understand
that my failure to promptly provide another consent may be grounds for termination of my agreement
with Four Winds Staffing LLC and/or grounds for my termination of Participation at or with the Entity.
I agree that information obtained in accordance with the provisions of this Authorization, Attestation, and
Release is not and will not be a violation of my privacy.
I certify that all information provided by me in my application is current, true, correct, accurate, and
complete to the best of my knowledge and belief, and is furnished in good faith. I will notify Four
Winds Staffing LLC, the Entity, and its Agent(s) within 10 days of any material changes to the information
(including any changes/challenges to licenses, DEA, insurance, malpractice claims, NPDB/HIPDB reports,
discipline, criminal convictions, etc.) that I have provided in my application or authorized to be released
pursuant to the credentialing process. I understand that corrections to the application are permitted at any
time prior to a determination of Participation by the Entity, and must be submitted online or in writing,
and must be dated and signed by me (may be a written or an electronic signature). I acknowledge
that Four Winds Staffing LLC, the Entity, and/or its/their Agent(s) will not process an application until
Four Winds Staffing LLC, the Entity, and/or its/their Agent(s) deems it to be a complete application and
that I am responsible to provide a complete application and to produce adequate and timely information
for resolving questions that arise in the application process. I understand and agree that any material
misstatement or omission in the application may constitute grounds for withdrawal of the application
from consideration and/or termination of my agreement with Four Winds Staffing; denial or revocation of
Participation; and/or immediate suspension or termination of Participation. This action may be disclosed to
the Entity and/or its/their Agent(s).&nbsp;I further acknowledge that I have read and understand the foregoing Authorization, Attestation, and Release
and that I have access to the bylaws of applicable medical staff organizations and agree to abide by
their bylaws, rules, and regulations. I understand and agree that a facsimile or photocopy of this
Authorization, Attestation, and Release shall be as effective as the original.

Standard Authorization, Attestation, and Release.

Signature

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Thank you!

Four Winds Standard Authorization Form