2000 East Lamar Boulevard #250 | Arlington, TX 76006
Phone: (855) 303-7587 | (866) 267-4466 | Fax: (800) 850-2005

Identifying Information (For Internal Purposes Only)
Professional Designation
Primary Contact Phone
Secondary Contact Phone
Desired Work Situation
Board Certifications
Professional References
Once you complete this form, your references will receive an email from your recruiter asking them to fill out a short Reference Form for you. This form usually takes less than 3 minutes to complete. It is confidential and will only be shared with any facility requiring references to be checked.

Release and Authorization

By my signature below, I authorize HospitalistsPlus (H+) to conduct background and reference checks on me regarding any information related to possible placement as a healthcare provider. This includes information on my education, licensing, work history, Medicare/Medicaid sanctions, malpractice claims and insurance eligibility, and criminal history. Rhino Medical Services may gather the information from various sources including, but not limited to, consumer reporting agencies, hospitals, medical institutions or organizations, personal references, physicians, employers (past and present), business and professional associates (past and present), governmental agencies and instrumentalities (local, state, federal, or foreign), university transcript offices, medical schools, and the Office of the Inspector General.

I authorize HospitalistsPlus (H+) to confirm information contained on any document that I provide HospitalistsPlus (H+), including my curriculum vitae. I consent to HospitalistsPlus (H+) sharing this information with HospitalistsPlus (H+) clients and affiliates. I understand that upon my request HospitalistsPlus (H+) will disclose the nature and scope of information contained in my file in accordance with federal law. A request for disclosure of information in my file must be made in writing and directed to my recruiting consultant.

I authorize the above-named entities and individuals to release to state licensing boards, hospitals, and HospitalistsPlus (H+), any information (written or oral), including medical information, files or records about me in their possession required for evaluation of my qualifications for placement as a locum tenens provider. I hereby release the above-named individuals and entities, including HospitalistsPlus (H+), from all liability for the release of information to any state licensing board, hospital, or its agents.

I further authorize HospitalistsPlus (H+), its agents, and affiliates to release this information, including medical information, to federal, state, county, or local government entities, hospitals or other healthcare facilities, insurance providers or any other person upon showing that the release of information is vital to the general public’s health, safety and welfare.

I make this release for the purpose of allowing HospitalistsPlus (H+) to assist in my request for a license to practice in my specialty and/or to assist in my efforts to work as a healthcare provider for HospitalistsPlus (H+) clients.

HospitalistsPlus is 100% dedicated to the staffing of Hospital Medicine, with more than 30years combined experience, we have held the reputation as leaders in health care staffing for the past decade.


2000 E Lamar Blvd Suite 250
Arlington, TX 76006
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