I, understand that by application for clinical privileges,at Alina Health LLC.(Company), I hereby signify my willingness to appear for interviews with regard to my application, authorize the organization, its medical staff, and their representatives to consult with members ofmanagement and members of medical staffs of other hospitals or institutions with which I have been associated and with others, including past and present malpractice insurance carriers, who may have information bearing on my professional competence, character, and ethical qualifications. I hereby further consent to inspections by the Company, its medical staff and its representatives of all records and documents, including medical and credential records at other hospitals, which may be material to an evaluation of my qualifications for staff membership. I hereby release from liability all representatives of the Company, its medical staff in their individual and collective capacities for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications and I hereby release from any liability and all individuals and Companywho provide information to the Companyor to members of its medical staff in good faith and without malice concerning my professional competence, ethics, character and other qualifications for staff appointment and clinical privileges.

I hereby consent to the release of information by other hospitals, other medical associations and other authorized persons, on request, regarding any information the Companymay have concerning me as long as such release of information is done in good faith and without malice, and I hereby release from liability the Companyfor so doing. I understand and agree that I, as an applicant for clinical privileges have the burden of producing adequate information for the proper evaluation of my professional competence, character, ethics and other qualifications and for the resolution of any doubts about such qualifications.By accepting appointment and/or reappointments to the Medical Staff of the facility, I hereby acknowledge and represent that I have read and am familiar with the Bylaws, Rules and Regulations of the Company, as well as the principles, standards and ethics of the national, state and local associations and state law and regulation that apply and govern my specialty and/or profession. I further agree to abide by the "Governing Standards" as may be enacted from time to time.In addition, I agree to notify the Companyof any circumstances that would change my status in licensure, DEA, Medicare participation, liability insurance coverage or Board certification or hospital privileges.I understand and agree that any significant misstatement in or omissions from this application shall constitute cause for denial of appointment or cause for summary dismissal from the medical staff with no right of appeal. All information submitted by me in this application is true to the best of my knowledge and belief.I further authorize a photo static copy of the requests, authorizations and releases to this application to serve as the original.