Consent and Release from Liability Statement

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Consent and Release from Liability Statement

I hereby authorize WorldWide Medical Staffing and/or any of its officers, employees, or agents to investigate my background, references, character, education, professional licenses and certifications, past employment, and/or criminal records in order to confirm my qualifications for employment as represented on my resume and/or employment application, and/or my employment interview. I understand that WorldWide Medical Staffing, certain states and/or Client institutions may require criminal background checks, and I consent to such checks.

I voluntarily consent and authorize WorldWide Medical Staffing or any of its officers, employees, or agents to check my references by contacting any person or entity whom they deem to be an appropriate reference. I understand that questions may be asked about my educational background, work experience, achievements, wage history, performance, attendance, personal history, character, personality, disciplinary information, and reason for separation from former employment.

I hereby authorize WorldWide Medical Staffing to consult with administration and members of any facility, hospitals, or institutions with which I have been associated, and with others, including past and present malpractice carriers, who may have information bearing on my professional competence, character, and ethical qualifications.

I hereby further consent to the inspections by WorldWide Medical Staffing, the clinical staff and their representatives, as my authorized agent, of all records and documents (not otherwise restricted) including medical records at other hospitals and facilities and the National Practitioner Data Bank (NPDB) that may be material to an evaluation of my professional qualifications and competence.

I hereby consent to the release of any and all such information to WorldWide Medical Staffing. It is expressly understood that any information given is to be used for the purpose of determining my acceptability for employment with WorldWide Medical Staffing. I further authorize WorldWide Medical Staffing to forward the results of the above queries and searches and to release information in support of my application to any facility or client at which I may be submitted for an assignment. WorldWide Medical Staffing may also share information regarding my employment with its affiliates and appropriate governmental or licensing entities.

WorldWide Medical Staffing respects the privacy of protected health information. We treat personal information securely and confidentially. We limit access to personal information to only those persons who need to know that information. These persons are trained on the importance of safeguarding this information and must comply with our procedures and applicable laws. We employ strict physical, electronic and procedural security standards to protect personal information and maintain internal procedures to promote the integrity and accuracy of that information.

I hereby release from liability any and all individuals and organizations that, in good faith and without malice, provided any and all information concerning my professional practice, competence, ethics, character and other qualifications to the officials of WorldWide Medical Staffing, including medical facility officers or authorized medical staff representatives, for staff appointment and clinical privileges.
I also hereby release WorldWide Medical Staffing from all liability for damages or claims – including, but not limited to, defamation, interference with contract, and negligence – which may arise or result from any reference information gathered pursuant to this authorization. By signing below, I release WorldWide Medical Staffing and/or its officers, employees, and/or agents, as well as any person or entity providing information on my background pursuant to this acknowledgment form, from any and all liability in relation to the information obtained from any and all of the above referenced sources used.

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  • (480) 467-4443

  • 3451 South Mercy Road
    Gilbert, AZ 85297


Monday – Friday 8:00a – 5:00p
Saturday & Sunday Closed