Most Recent Training Specialty Date of training City State Zip

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1 PRE-APPLICATION FOR APPOINTMENT TO THE MEDICAL STAFF Last Name First Name Middle Name Social Security # - - Other/Maiden Name Used Specialty Address Cell Phone # ( ) Date of Birth (Mo/Day/Yr) Place of Birth Citizenship Sex / / M F Primary Office Address Street Address City State Zip CA Telephone Number FAX Number Office contact (name) Office contact ( ) ( ) Secondary Office Address Street Address City State Zip CA Telephone Number FAX Number Backline Number ( ) ( ) ( ) Home Address Street Address City State Zip Telephone ( ) Most Recent Training Specialty Date of training City State Zip Board Certified Specialty & Date Obtained 2 nd Board Certified Specialty & Date Obtained You have requested an application for the Medical Staff at: Mission Hospital and/or CHOC Children s at Mission Hospital (CCMH) Prior to being sent an application packet, you will need to complete this form and return it with the items listed below. Copy of current California medical license (wallet card). Copy of current DEA certificate. Copy of current Board Certification Two passport-size recent photographs. Copy of current Driver s license Copy of Social Security card Copy of your U.S. Passport or certified Birth Certificate OR- Copy of Naturalization Papers or Work Visa Copy of current CA Fluoroscopy License for physicians in the following specialties: Gastroenterology; Pain Mgmt; Radiology; Neuro, Orthopedic, Podiatric & Trauma (General) Surgery,and/or any other physician who will operate the C-ARM. Copy of current certification for: FOR MISSION HOSPITAL: FOR CHOC CHILDREN S AT MISSION HOSPITAL: Anesthesiologists/ Pain Mgmt ACLS Anesthesiologists/ Pain Mgmt ACLS or PALS Attendance at C-Section NRP Neonatologists/Attending in NICU NRP Trauma (General) Surgeons ATLS and ACLS Peds. Critical Care ACLS, PALS or NRP Obstetricians NRP Trauma (General) Surgeons ATLS and ACLS Moderate Sedation Privileges ACLS or PALS Current malpractice liability insurance declaration of coverage (minimum amount of $1 million/$3 million) AND claims history, including any claims closed without payment. Completed Covering Physician Verification Form and ALL other pre-application forms included in this packet. *Non-refundable Processing Fee, made payable to MISSION HOSPITAL For Mission Hospital -- $600 For CCMH -- $200 For both hospitals -- $800 *Medical Staff Dues (for the first year of membership) For Mission Hospital, $350 made payable to Mission Hospital Medical Staff For CHOC Children s at Mission Hospital, $200 made payable to CHOC at Mission Medical Staff NOTE: If application is denied or withdrawn, only these dues are refundable. After your completed Pre-application is received, the Application packet is available via . Address to send the Application to: Do not . Mail application to: Primary Office address Send completed pre-application to: Home address Other address: Medical Staff Services Office Page 1 of Medical Center Road, Mission Viejo, CA (949) F (949) Rev. 1/2013

2 COVERING PHYSICIAN VERIFICATION FORM I,, have discussed coverage of my patients with the below named physicians and he/she/they agreed to provide coverage for my patients while hospitalized at Mission Hospital and/or CHOC Children s at Mission Hospital (CCMH). Their printed names and signatures attest to that coverage agreement. Note* A minimum of one covering physician in your specialty (or specialties) is required. Applicant s Signature Date Covering Physicians: Page 2 of 7

3 MEDICAL STAFF HOSPITALIST PREFERENCE In order to provide better service for our patients requiring admission to the hospital, the Medical Staff maintains a database of all Medical Staff members preference for their private (non managed care) patients requiring admission to the hospital. Mission Viejo preference: Please indicate who you would like to admit your private (non managed care) patients. I will admit my own private patients. I use Dr. to admit all my private patients. I use Hospitalist Group* to admit all my private patients. Laguna Beach preference: If you use both campuses and want to designate a different Hospitalist Preference at Laguna Beach, please indicate that here: I will admit my own private patients. I use Dr. to admit all my private patients. I use Hospitalist Group* to admit all my private patients. Request made by Dr. (Please print your name) Your signature *Hospitalist Groups For additional information on group physicians call: Elite Hospitalists (Huan Guu, MD) (866) Memorial Care Medical Group (formerly Bristol Park Med Group) (714) Mission Internal Medical Group (MIMG) (949) Orange County Hospitalist Physicians (OCHP) (949) Pacific Hospitalist Associates (PHA) (866) Paloma Medical Group (949) Private Hospitalist Medical Group No central number Saddleback Pulmonary Associates (949) If you have additional questions, contact the Medical Staff Office at (949) Page 3 of 7

4 ACKNOWLEDGEMENT OF BOARD CERTIFICATION REQUIREMENT The following requirement for Board Certification is included in the Mission Hospital Medical Staff Bylaws, provided to you in your original packet. Please acknowledge your agreement to progress toward Board Certification, in the time frame noted, by signing at the bottom and returning to the Medical Staff Services Office. ARTICLE III - MEMBERSHIP IN MEDICAL STAFF Section 2. Qualifications for Membership E. (1) Specialty board, as used in this section, means a national specialty board of, or recognized by, the American Board of Medical Specialties, the American Osteopathic Association, the Council on Podiatric Medical Education, the American Board of Dentistry, or the American Board of Addiction Medicine. (2) A practitioner applying for appointment or reappointment to the Medical Staff and/or for the granting or extension of clinical privileges must, at the time of application, be certified by the specialty board pertaining to the practitioner s clinical privileges. Notwithstanding this requirement, a practitioner who completed his or her training program less than five years prior to his or her application for appointment or reappointment may be granted membership and privileges; however, such practitioner must become board certified within five (5) years from the practitioner s completion of his or her training program. Failure to become board certified in the time allowed shall render the practitioner ineligible for reappointment. An extension of this five (5) year time period will be granted only under extraordinary circumstances and for demonstrated good cause as determined solely at the discretion of the Medical Executive Committee and the governing body. Board certification must correspond to the clinical privileges requested and program completed. The requirement for Board Certification does not apply to licensed clinical psychologists. (3) Except otherwise provided below, all Medical Staff members are required to maintain board certification throughout their membership on the Medical Staff. Therefore, Medical Staff members must obtain recertification from the specialty board pertaining to the practitioner s clinical privileges if recertification is required in order to maintain board certification. Failure of a practitioner to maintain board certification shall result in the automatic termination of his or her Medical Staff membership and privileges. A practitioner whose Medical Staff membership and privileges are terminated for failing to maintain board certification is not entitled to the hearing and appeal rights in Article X of these Bylaws. (4) If a current medical staff member fails the re-certification examination, he may request an extension of his membership and privileges for a time period not to exceed two months after the next recertification examination is offered. Included in the medical staff member s request for an extension must be a copy of the letter from the board which notified him of the results of the examination and the date of the next recertification examination. The medical staff member must take the next scheduled examination and forward the results of the examination to the Medical Executive Committee prior to consideration of his reappointment. If the medical staff member does not become re-certified at this second attempt, paragraph E. (2) shall apply. Medical staff members who do not take the re-certification examination prior to the expiration of their appointment may not request an extension of his membership and privileges according to this paragraph, but may request an extension for extraordinary circumstances under paragraph E.(2) above. (5) Medical Staff members who have maintained continuous Medical Staff membership since January 2002, and who are ineligible to apply for board certification by the specialty board pertaining to the practitioner s clinical privileges, may be considered for renewal of medical staff membership if they can document sufficient training, experience, and competence, and otherwise meet the requirements of medical staff membership. This exception does not apply to Medical Staff members who are eligible to take the board certification examination(s), but have not obtained board certification. Physician Signature Date Page 4 of 7

5 ACKNOWLEDGEMENT OF BOARD CERTIFICATION REQUIREMENT The following requirement for Board Certification is included in the CHOC Children s at Mission Hospital Medical Staff Bylaws, provided to you in your original packet. Please acknowledge your agreement to progress toward Board Certification, in the time frame noted, by signing at the bottom and returning to the Medical Staff Services Office. ARTICLE III MEMBERSHIP ON MEDICAL STAFF Section 2. Qualifications for Membership D. A practitioner applying for appointment to the Medical Staff and for the granting or extension of clinical privileges must have been or become, whichever is appropriate, certified by the national specialty board pertaining to the practitioner s clinical privileges of the American Board of Medical Specialties, the American Osteopathic Association, or the American Board of Dentistry within five (5) years from the completion of the practitioner s training program. Board certification must correspond to the clinical privileges requested and program completed. An extension of this time period or exemption from these requirements will be granted only under extraordinary circumstances and for demonstrated good cause as determined solely at the discretion of the Medical Staff Executive Committee and the governing body. If the Medical Staff applicant or member is required by the specialty board to re-certify in order to maintain board certification, the practitioner must become re-certified in order to obtain and/or maintain Medical Staff membership and clinical privileges unless exempted by the above paragraph. Physician Signature Date Page 5 of 7

6 Clinical Privileges Forms (Control Cards) The Privileges Forms that you select from the list below will be included with your application. Your selection must be supported by current competency documentation in the form of training logs or healthcare facility activity reports for the last 24 months. Check as applies to you: For the privileges form(s) I am requesting below, I am currently Board Certified*. For the privileges form(s) I am requesting below, I am currently in the Board Certification process*. I completed my training for my primary specialty in the year. Secondary specialty in the year. If your practice includes patients under the age of 18 y/o, you will need to apply to CHOC Children s at Mission Hosp also. Active Community-No admitting/clinical privileges Ophthalmology Addiction Medicine Orthopedics Allergy and Immunology Otolaryngology Anesthesia Pain Management Cardiology Pathology Dentistry & Oral Maxillofacial Surgery Pediatrics Dermatology Physical Med & Rehab Emergency Medicine Plastic Surgery Endocrinology Podiatry Endovascular Psychiatry Family Medicine Psychology Gastroenterology Radiation Oncology General Surgery Radiology Hematology, Oncology Rheumatology Infectious Diseases Sedation [Deep, Dissociative, Moderate & IV Regional] Internal Med,Pulmonary & Critical Care Teleradiology Nephrology Thoracic & Cardiovascular Surgery Neurology Urology Neurosurgery Vascular Surgery OB-GYN *MH Bylaws require Board Certification pertaining to the privileges being requested within five (5) years from the completion of the practitioner s training program. See Acknowledgement of Board Certification Requirement included in packet for more details. Rev. 6/2012 Page 6 of 7

7 Clinical Privileges Forms (Control Cards) The Privileges Forms that you select from the list below will be included with your application. Your selection must be supported by current competency documentation in the form of training logs or healthcare facility activity reports for the last 24 months and must be broken down by the patient s age or DOB. Check as applies to you: For the privileges form(s) I am requesting below, I am currently Board Certified*. For the privileges form(s) I am requesting below, I am currently in the Board Certification process*. I completed my training for my Primary specialty in the year. Secondary specialty in the year. CCMH Active Community No admitting/clinical privileges CCMH Nephrology CCMH Allergy CCMH Neurology CCMH Anesthesia CCMH Neurosurgery CCMH Cardiology CCMH Ophthalmology CCMH Clinical Psychology CCMH Orthopedics CCMH Critical Care CCMH Otolaryngology CCMH Dentistry, Oral- Maxillofacial Surgery CCMH Pathology CCMH Dermatology CCMH Pediatrics CCMH Emergency Medicine CCMH Physical Med & Rehab CCMH Endocrinology CCMH Plastic Surgery CCMH Family Medicine CCMH Podiatry CCMH Gastroenterology CCMH Psychiatry CCMH General Pediatric Surgery CCMH Pulmonary CCMH Genetics CCMH Radiology CCMH Gynecology CCMH Rheumatology CCMH Hematology, Oncology Sedation [Deep, Dissociative, Moderate & IV Regional] CCMH Hospitalist Care CCMH Teleradiology CCMH Infectious Diseases CCHM Thoracic & Cardiovascular Surgery CCMH Internal Medicine CCMH Urology CCMH Neonatology *CCMH Bylaws require Board Certification pertaining to the privileges being requested within five (5) years from the completion of the practitioner s training program. See Acknowledgement of Board Certification Requirement included in the packet for more details. Rev. 6/2012 Page 7 of 7