SGPA Application

Practicing Specialty (-ies):

Physician Demographics:

Current Physician Organization Affiliations:

Primary Physical Office Location:

Billing Information For Primary Physical Office Location:

Call Coverage for this Location Provided By:

Additional Office Location: 1

Billing Information For Primary Physical Office Location:

Call Coverage for this Location Provided By:

Additional Office Location:2

Billing Information For Primary Physical Office Location:

Call Coverage for this Location Provided By:

Additional Office Location: 3

Billing Information For Primary Physical Office Location:

Call Coverage for this Location Provided By:

Attestation:

I the undersigned, do hereby attest that the statements and responses that I have provided in this addendum, are to the best of my knowledge and recollection, complete and correct and that I have not deliberately omitted, misrepresented or misstated any material fact(s). I agree to indemnify and hold harmless South Georgia Physicians Association, L.L.C., its respective officers, directors, agents and employees against any and all claims, demands, damages, liabilities, losses, costs and expenses including attorneys fees incurred as a result of any false, incomplete or outdated information contained in this application. I understand that falsification of any of these statements or responses, or omissions of any material fact may result in my inability to participate in, or continue to participate in South Georgia Physicians Association, L.L.C.

Authorization to Release Information:

I understand that submission of this application does not imply or guarantee acceptance or membership in South Georgia Physicians Association, L.L.C. I acknowledge and understand that South Georgia Physicians Association, L.L.C. (“SGPA”) has a legitimate right to obtain and verify any information regarding my professional competency. Therefore, I the undersigned Provider do hereby authorize SGPA and their authorized representatives to consult with any third party who may have information including otherwise privileged or confidential information, relating to my professional qualifications, credentials, professional competence, physical, mental or emotional condition, moral or ethical character, or any other matter relating to this application or affiliation with SGPA. I also authorize any third party, including but not limited to medical associations/societies of which I am a member, all hospitals or other healthcare facilities in which I have held or now hold privileges, any state licensing board to which I ever applied or been granted a professional license, other physicians or healthcare providers, government agencies, peer review or professional standards review organizations, managed care organizations, state public health department and professional liability insurers, to release to SGPA and their authorized representatives upon their request, any information any such third party may have which, in the judgment of any such third party, has a bearing upon my acceptability to SGPA. I also agree to indemnify and hold harmless SGPA, its respective officers, directors, agents and employees and any third party releasing information pursuant to this authorization from any and all claims, damages, liabilities, costs and expenses including attorneys fees incurred by these persons, organizations or entities for releasing such information.