ED Managment Services at Correct Care, Inc.

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By checking this box, I am stating that the information given is true and complete to the best of my knowledge. I understand that any false or misleading statements given by me to CCI may constitute grounds for my dismissal. 1 give CCI authority to contact references both listed and not listed by me in an attempt to perform a standard background check and investigation of both my professional and personal histoy. Either an original or photostatic copy of this authorization shall be valid.

1 hereby release from liability all representatives of Correct Care Inc., the Hospital or its Medical Staff, or any 3rd party credentialing agencies for their acts performed in good faith and without malice in connection with evaluating my application, credentials and qualifications. 1 also hereby release from any liabilitv any individuals and organizations who provide information to the Hospital, or its Medical Stalff, in good faith and without malice concerning my professional competence, ethics, character and other qualifications for staff appointment and clinical privileges, and I hereby consent to the release of such information.

Please type your full name below to indicate you have read and understand the above statement.