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Practice Information
Education & Training (for highest degree received)
Internship Information
Residency Information
Professional References
Reference 1
Reference 2

I fully understand that if any information provided in this application is false, or becomes false, without my giving notification to Quest Behavioral Health by certified mail within 15 days of such information becoming false, Quest Behavioral Health will be entitled to terminate my provider agreement for breach. All information submitted by me in this application is warranted to be true, correct, and complete.

I authorize Quest Behavioral Health and/or its Agents to consult with the National Practitioner Data Bank, state licensing board(s) educational institutions, specialty boards, malpractice insurance carriers, Educational Council for Foreigh Medical Graduates, hospitals, professional references, and any other person or entity from whom/which information may be needed to complete the credentialing process or to obtain and verify information concerning my membership, professional competence, character and moral and ethical qualifications, and I hereby authorize all of them to release such information to Quest Behavioral Health and/or its Agents. I release Quest Behavioral Health, its employees and Agents and all those whom Quest Behavioral Health and/or its Agents contact from any and all liability for their acts performed in good faith and without malice in obtaining and verifying such information and in evaluating my application.

I consent to the release by any person to Quest Behavioral Health and/or its Agents of all information that may reasonably be relevent to an evaluation of my professional competency, character and moral and ethical qualification, including any information relating to any disciplinary action or suspension or curtailment of privileges, and hereby release any such person providing such information from any and all liability for doing so.