I hereby authorize BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (BCBSND), its professional staff and legal representatives, to contact and consult with administrators and members of the professional staff of any treatment facility, institution, professional society, school, employer, law enforcement agency, or practice with which I have been associated, for the purpose of evaluating my professional competence, character, criminal history and ethical conduct. In addition, I consent to the inspection of all records and documents, including health records at other treatment facilities that may be material for evaluation of my professional qualifications by BCBSND, its professional staff and legal representatives. I release from liability all individuals or organizations for acts performed in good faith and without malice honestly initiated and in response to the inquiries authorized for use by BCBSND. I consent to the use of an electronic signature and understand that by typing my name in the signature space or (print name*) space in the Consent section of this application, I am affixing my electronic signature which has the same legal effect and enforceability as my handwritten signature. I agree that a photocopy of this authorization may be accepted with the same authority as the original.
I certify and attest to the fact that all of the information I have submitted in this application is complete, true and accurate to the best of my knowledge and belief.
