• 1. Authorization: I hereby authorize the Congress of Neurological Surgeons (hereinafter referred to as the “Congress”) and its board of directors, membership committee, professional conduct committee, or any of their employees and agents (each a Congress representative) to:

    consult or make inquiry of any physician, hospital, health system, medical school, medical training program, medical association, specialty board, licensing authority, professional liability insurance carrier, broker or agent, personal reference, individuals and/or organizations concerned with provider performance and the quality and efficiency of patient care, and individual or organization who has been associated with me and/or who has information bearing on my ability, training, education, professional ethics, character, emotional stability, professional liability experience, and other qualifications pertinent to membership in the Congress;

    AND

    inspect and obtain copies of all records and documents that may be material to evaluating my professional qualifications, competence, ethical standards and practice patterns or otherwise related to qualifications pertinent to membership in the Congress.

    2. Release: I hereby authorize and consent to the release of information by:

    each individual and organization who provides information to the Congress or its representative in good faith concerning my ability, training education, professional ethics, character, emotional stability, professional liability experience, and other qualifications pertinent to membership in the Congress, including otherwise privileged or confidential information;

    AND

    The Congress and representatives to any physician, hospital, medical school, medical training program, medical association, specialty board, licensing authority, professional liability insurance carrier, broker or agent, personal references, and individuals or organizations concerned with provider performance and the quality and efficiency of patient care, any information relevant to such matters that the Congress or its representatives may have concerning me regarding my ability, training, education, professional ethics, experience and other qualifications pertinent to membership in the Congress.

    3. Indemnification: I hereby discharge from any liability and agree to indemnify, defend and hold harmless from any liability (including reasonable attorney’s fees and expenses) all:

    • Individuals and organizations who provide information to Congress in good faith, including otherwise privileged or confidential information; and
    • Congress and Congress representatives

    For their acts performed in good faith in connection with obtaining or providing information about me and evaluating my credentials and qualifications.

    I hereby agree that no information obtained by the Congress or its representatives pursuant to any pre-application, application or re-application process shall be subject to discovery, subpoena or other means of legal compulsion for release by me or my agents.

    4. Truth and accuracy of information: I hereby certify that all information submitted by me to the Congress (whether in an application, CV or otherwise) is true to my best knowledge and belief. I understand and agree

    i. to update the Congress so that all information contained in my application for membership remains true at all times; and

    ii. that providing false or misleading information shall be grounds for denial or termination of membership in the Congress without right to further process.

    5. Membership Dues and Assessments: I hereby acknowledge financial responsibility to timely pay all membership dues and other financial assessments imposed on my by the Congress.

    6. Membership Pledge: I pledge that at all times while I am a member of the Congress to uphold the ideals and goals of the Congress and to continuously strive to provide quality and efficient care to my patients in a cost effective manner. I confirm that I have not had any previous disciplinary actions (e.g.: loss of membership in other medical societies, etc.) and I am committed to an ethical medical practice.

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