Upon approval of your credentials, attendance at a 3 hour orientation session will be mandatory.

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1 Dear Allied Health Applicant: Thank you for your interest in Nicklaus Children s Hospital. Per your request, I have enclosed an application for Allied Health Professionals. Please complete all forms, provide appropriate documentation as outlined and return them to the Medical Staff Office for processing. In the event it is determined that you do not meet the qualifications of Nicklaus Children's Hospital, your application will not be processed and you will be advised accordingly. The credentialing process takes approximately six to eight weeks for completion. During this time, all information provided will be verified in writing, written references will be obtained and appropriate background screenings will be conducted. Your application will be considered complete when all requested information has been provided and verified and the non-refundable application fee of $200 has been received. You will be notified in writing of the Board of Directors' decision after recommendation of the Allied Health Credentials Subcommittee, Credentials Committee and the Medical Executive Committee. Upon approval of your credentials, attendance at a 3 hour orientation session will be mandatory. If you have any questions regarding your application, feel free to contact the Medical Staff Office at (305) Sincerely, Ileana R. Salman Medical Staff Credentialing Manager :irs Enclosures menocal/ahp/ahp application cover Medical Staff Services SW 62 Avenue, Miami, FL (305) /Fax:(305)

2 ALLIED HEALTH PROFESSIONALS APPLICATION DOCUMENTATION CHECKLIST Please return the following items, so that we may process your application expeditiously: Application Form (completed and signed on pages 4 and 5) Note: Professional References can not be from family members) Functions & Duties Form (completed and signed by applicant and supervising physician) Evidence of competency if requesting Suturing, Insertion/Removal of Catheters/Tubes, or any other item not listed on the Functions & Duties Form. Three letters of reference from clinicians who are familiar with your competency Copy of college/university/professional school diploma Copy of Board Certification (if applicable) Copy of Florida license(s), Certificate or Registration Evidence of current professional liability insurance (Not applicable for Nicklaus Children s Hospital Employees) Explanation of malpractice claims (if any) Evidence of continuing education (CE s) for the past year (for ARNP s, PA s, RN s) Curriculum Vitae (CV)/ Resume (must have employment and education in Month/Year format) One (1) color passport size photograph Copy of Drivers License OR Passport Copy of Social Security Card (must be signed) Copy of valid CPR Card (must be American Heart Association (AHA) approved course) Certification of Health (letter from your primary care physician attesting to your health status) Copy of completed Supervision Data Form (for PA s Form Attached) Copy of ARNP Protocols (for ARNP s Sample Protocols Attached) Orientation Acknowledgement Form (Not applicable for Nicklaus Children s Hospital Employees) $200 non-refundable application fee (payable to Nicklaus Children s Hospital Medical Staff Fund )

3 ALLIED HEALTH PROFESSIONALS APPLICATION Name In Full: Any Other Name Used: Date: Address: Supervising Physician: Office Address: Home Address: Cell Phone #: Date of Birth: Phone: Fax: Phone: Spouse s Name: NPI # (for NP s & PA s only): Place of Birth: Citizenship: Social Security #: Medicaid Provider # Medicare Provider # COLLEGES, UNIVERSITIES (OR OTHER SCHOOLS) ATTENDED: Institution Name: Dates: to Address: Degree: Institution Name: Dates: to Address: Degree: HOSPITAL STAFF APPOINTMENTS - List other hospitals in the community where you are affiliated: Hospital Name: Dates: to Address: Degree: Hospital Name: Dates: to Address: Degree: Nicklaus Children s Hospital / 3100 SW 62 Avenue / Miami, Florida / Phone: (305) / Fax: (305) Page 1

4 STATE LICENSURE: Are you licensed or certified: YES NO If "YES", what type: License or Registration Number: Exp. Date: CERTIFICATION List any board certifications: Board Name: Board Name: Date Certified: Date Certified: PROFESSIONAL MEMBERSHIPS List any professional, society memberships: PROFESSIONAL REFERENCES List name and complete address of three peer references familiar with your clinical skills and professional competence (i.e., former supervising physicians, colleagues) Do not include family members. List peers who are familiar with your professional competency and clinical skills in a supervisory capacity. Name: Address: Relationship/Title: Phone: Fax: Name: Address: Relationship/Title: Phone: Fax: Name: Address: Relationship/Title: Phone: Fax: Nicklaus Children s Hospital / 3100 SW 62 Avenue / Miami, Florida / Phone: (305) / Fax: (305) Page 2

5 PROFESSIONAL LIABILITY INSURANCE: Name of Present Carrier: Agent Address: Coverage Limits: Phone: Expiration Date: Please answer "YES" or "NO" in space provided after each of the following questions. If answer is "YES", please give complete details on a separate sheet of paper. 1. Has your license to practice your profession in any jurisdiction been voluntarily or involuntarily limited, suspended, revoked, denied, subjected to probationary conditions, or relinquished; or have challenges or proceedings toward any of those ends been instituted? 2. Have your clinical privileges at any other hospital or health institute been voluntarily or involuntarily limited, suspended, revoked, not renewed, subjected to probationary conditions, or relinquished; or have proceedings toward any of those ends been instituted or recommended by a Medical Staff Committee or the Governing Board? 3. Has your Medical Staff membership or Medical Staff status at any hospital or health care institution been voluntarily or involuntarily limited, suspended, revoked, not renewed, subjected to probationary conditions (excluding initial conditions routinely placed on all such privileges at the institution), or relinquished; or have proceedings toward any of those ends been instituted or recommended by a Hospital, Medical Staff Committee, officer or an institutional Governing Board? 4. Has your request for any specific clinical privilege been denied or granted with stated limitations (excluding initial limitations routinely placed on all such privileges at the institution); or has such a denial or limitation been recommended by a Hospital or Medical Staff Committee or officer or a Governing Board? YES NO YES NO YES NO YES NO 5. Have you been denied membership or renewal thereof or been subject to any disciplinary action or revocation in any medical organization or professional society (local, state, or national); or have proceedings toward any of those ends been instituted? YES NO 6. Has your Drug Enforcement Agency or other controlled substances authorization been voluntarily or involuntarily denied, revoked, suspended, reduced, relinquished, or not renewed; or have proceedings toward any of those ends been instituted? 7. Have you ever been suspended, fined, disciplined, sanctioned or otherwise restricted or excluded from participating in any federal or state health insurance program (for example, Medicare or Medicaid)? 8. Have you ever been suspended, fined, disciplined, sanctioned or otherwise restricted or excluded from participating in any private health insurance program? 9. Has any professional review organization under contract with Medicare or Medicaid ever made an adverse quality determination concerning your treatment rendered to any patient? YES NO YES NO YES NO YES NO Nicklaus Children s Hospital / 3100 SW 62 Avenue / Miami, Florida / Phone: (305) / Fax: (305) Page 3

6 10. Have you been excluded or had any change in participation in any federal health program, including, but not limited to, exclusions or other sanction(s) imposed or recommended by the Federal Department of Health and Human Service's Office of the Inspector General, General Administrative Services or any other federal or state agency? 11. Have you ever been convicted of or entered a plea for any criminal offense (includes motor vehicle offenses, but not including minor traffic or parking violations)? YES NO YES NO 12. Have you been convicted of a felony? YES NO 13. Are any criminal charges currently pending against you? YES NO 14. Have you ever been arrested for or charged with a crime involving children? YES NO 15. Have you ever been arrested for or charged with a sexual offense? YES NO 16. Have you ever been arrested for or charged with a crime involving moral turpitude? YES NO 17. Have you been denied professional liability insurance or has your policy been canceled? YES NO 18. Have you been named in any malpractice suits? YES NO 19. Have any final settlements or judgments been made in any malpractice suits in which you were named as a defendant? 20. Do you have any personal, professional or financial affiliations or relationships which would foreseeably result in a conflict of interest with your activities or responsibilities at Nicklaus Children's Hospital? YES NO YES NO 21. Are you currently using illegal drugs or legal drugs in an illegal manner? YES NO 22. Have you ever participated in the Professional Resource Network or other impaired practitioners program? 23. Do you currently have any physical or mental condition(s) that may affect your ability to practice or exercise the clinical privileges or responsibilities typically associated with the specialty and position for which you are submitting this Application? 24. Have you ever withdrawn your request for membership or renewal thereof in any medical organization or professional society (local, state or national)? YES NO YES NO YES NO TUBERCULIN ASSESSMENT: Please check ( ) one: I have had a TB skin test within the previous 24 months and it was negative. I have a known positive skin test for TB; I have no signs or symptoms of active disease. If needed, TB skin testing may be obtained by the Nicklaus Children s Hospital Employee Health Office ( ). Appointments are required. Nicklaus Children s Hospital / 3100 SW 62 Avenue / Miami, Florida / Phone: (305) / Fax: (305) Page 4

7 IMMUNIZATIONS: Please check ( ) each item indicating your understanding: I am aware that immunity to Varicella, Measles, and Pertussis is required for persons having patient contact activities at Nicklaus Children s Hospital. I am aware that annual influenza vaccine is strongly recommended for all persons who work in health care. I am aware that records of Hepatitis B immunization/declination are to be maintained at my private office. I am aware that immunizations are available through the Nicklaus Children s Hospital Employee Health Office ( ). Appointments are required. INFECTION CONTROL: I am aware that compliance with Infection Control protocols that relate to my practice at Nicklaus Children s Hospital is required. EXPOSURES: I am aware that Nicklaus Children s Hospital will provide follow-up and referrals for exposures to communicable disease and/or exposures to blood and body fluids. Contact Employee Health Office ( ) or Infection Control ( ). In making application for Allied Health Professional authorization at Nicklaus Children's Hospital, I certify that I am physically and mentally capable of conducting my medical/dental duties and have no dependency on drugs and/or alcohol. I am able to perform all the essential functions of the position for which I am applying, safely and according to accepted standards of performance, with or without reasonable accommodation. I agree to report any changes in my health status that might affect my ability to practice, and agree to submit to a health examination acceptable to the Credentials Committee or Medical Executive Committee of Nicklaus Children's Hospital should this be considered necessary. I understand that the submission of this application does not in itself constitute an approval by Nicklaus Children's Hospital. If approved, I shall perform only those professional activities authorized and only upon direct supervision/responsibility of an attending physician of Nicklaus Children's Hospital Medical Staff or, to the extent authorized, of appropriate Nursing Staff (Clinical Specialist). I have received and have had an opportunity to read a copy of the Medical Staff Bylaws of the Hospital, and I specifically agree to abide by the Nicklaus Children's Hospital Medical Staff Bylaws, Rules and Regulations, Hospital Bylaws, hospital policies, directives and the code of ethics of my profession, as amended from time to time. I understand and agree that I have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubts about such qualifications. I authorize Nicklaus Children's Hospital to verify any and all information included in this application. I authorize anyone with information which will assist in this verification to release the information to Nicklaus Children's Hospital. Signature: Date: Nicklaus Children s Hospital / 3100 SW 62 Avenue / Miami, Florida / Phone: (305) / Fax: (305) Page 5

8 CONSENT FOR RELEASE OF INFORMATION - (Please read carefully before signing): I release from any liability all representatives of Nicklaus Children's Hospital, its Medical Staff, the Credentials Committee, the Medical Executive Committee, the Board of Directors and any other individuals for their acts performed in good faith and without malice concerning my professional and personal competence, character and other qualifications for Allied Health Professional authorization in said hospital. I further signify my willingness to appear for interviews in regard to this application. I authorize the hospital to consult with members of the Medical Staffs of other hospitals with which I have been or am presently associated who may have information bearing on my competence, character and ethical qualification. I consent to the hospital's inspection of all records and documentation of competence to carry out the functions and duties I have requested. Name (Please Print): Signature: Specialty: Date: P H O T O THIS SECTION TO BE COMPLETED BY SUPERVISING PHYSICIAN: STATEMENT OF SUPERVISING PHYSICIAN: I hereby verify that is in my employment or in a supervisory relationship with me in the capacity of. He/She will be under my direction at all times, and I agree to assume full responsibility for his/her actions in dealing with my patients who are hospitalized at Nicklaus Children's Hospital. I also agree to notify the Hospital if this person should ever leave my employment or supervisory relationship. Supervising Physician Name: (Please Print) Signature: Specialty: Date: DIRECTOR\AHP\AHP APPLICATION.DOC 03/15 Nicklaus Children s Hospital / 3100 SW 62 Avenue / Miami, Florida / Phone: (305) / Fax: (305) Page 6

9 ALLIED HEALTH PROFESSIONALS FUNCTIONS & DUTIES Physician Assistants & Nurse Practitioners NAME: TITLE OF LICENSE: Please list specific functions and duties you wish to perform as permitted within your license and practice act. APPLICANT PLEASE CHECK PHYSICIAN CHECK BOX ALLIED HEALTH CREDENTIALS COMMITTEE Physician Assistants may order controlled substances pursuant to their practice act and in agreement with their supervising physician. (Co-signature is not required) REQUESTED Approved Not Approved Approved Not Approved Nurse Practitioners may write verbal orders for controlled substances in consultation with their supervising physician, pursuant to their practice act. (Such orders must be co-signed with 24 hours) LEVEL 3 CORE: Physician Assistants & Nurse Practitioners: Requires advanced educational preparation. Formal supervisory relationship, standing orders, and established protocols with a physician Performs histories Performs physicals Orders x-rays and lab tests as indicated by established protocol Collects and interprets data Makes direct referrals - orders consults May alter/adjust medication dosages pursuant to an established protocol or supervision data form Management of minor illnesses/injuries as indicated by established protocols; may initiate appropriate therapies; may write orders Teaches patient and family Rounds on each patient under the auspices of supervising physician Notes patient progress on progress notes Debrides, cares for superficial wounds (excludes suturing) Removes sutures, hemovacs, other wound drains Draws blood samples (venipuncture) Performs incision and drainage of abscess and other simple procedures Writes discharge orders, instructions, summaries.

10 Please list specific functions and duties you wish to perform as permitted within your license and practice act. APPLICANT PLEASE CHECK PHYSICIAN CHECK BOX ALLIED HEALTH CREDENTIALS COMMITTEE Sutures superficial wounds. (*Must provide evidence of suturing competency) REQUESTED Approved Not Approved Approved Not Approved Inserts or removes catheters, tubes under the auspices of the supervising physician. (*Must provide evidence of competency) Please specify: Assists in Surgery Ability to assess the presence or absence of emergency medical conditions of patients presenting for emergency care, under the auspices of the supervising physician. Functions and duties granted shall be commensurate with the education, training, experience, judgment, character, and current capability and competency of the candidate. No allied health personnel shall be granted duties in excess of those permitted by provision of Florida Statutes or Hospital Guidelines. I APPLY FOR LEVEL 3 FUNCTIONS AND DUTIES. Applicant Signature Supervising Physician Signature Committee Signature Date: Date: Date: 06/15 DIRECTOR\AHP\LEVEL-3.DOC

11 SUPERVISION DATA FORM IMPORTANT: THIS FORM MUST BE UPDATED BY THE PHYSICIAN ASSISTANT AS A CONDITION OF PRACTICE Pursuant to s (7)(e) and s (7)(d), F.S., upon employment, a licensed physician assistant must notify the department in writing within 30 days after such employment and after any subsequent changes in supervision. Council on Physician Assistants, 4052 Bald Cypress Way, Bin #C-03, Tallahassee, Florida ***** PLEASE PRINT ***** Name: First Middle Initial Last Florida Physician Assistant license number: PA Print your current mailing address: All current practice locations: (1) Facility name: (2) Facility name: (3) Facility name: (4) Facility name: Make additional copies of page 1 as needed. Return all 5 pages. This Supervision Data Form will not be processed without the Physician Assistant s signature and date. DH-MQA 2004, Rules 64B and 64B , Revised 08/10 1

12 I am ADDING the following supervising physician(s). PLEASE PRINT Name and license number of supervising physician(s) Specialty of supervising physician Beginning date of Supervision Make additional copies of page 2 as needed DH-MQA 2004, Rules 64B and 64B , Revised 08/10 2

13 I am DELETING the following supervising physician(s). PLEASE PRINT Name and license number of supervising physician(s) Effective date of deletion Make additional copies of page 3 as needed DH-MQA 2004, Rules 64B and 64B , Revised 08/10 3

14 I am ADDING the following practice location(s). PLEASE PRINT (1) Facility name: (2) Facility name: (3) Facility name: (4) Facility name: (5) Facility name: (6) Facility name: (7) Facility name: (8) Facility name: Make additional copies of page 4 as needed DH-MQA 2004, Rules 64B and 64B , Revised 08/10 4

15 I am DELETING the following practice location(s). PLEASE PRINT (1) Facility name: (2) Facility name: (3) Facility name: (4) Facility name: (5) Facility name: (6) Facility name: Signature of Physician Assistant Date of signature: Return all 5 pages. This Supervision Data Form will not be processed without the Physician Assistant s signature and date. DH-MQA 2004, Rules 64B and 64B , Revised 08/10 5

16 NICKLAUS CHILDREN S HOSPITAL #7430 PRACTITIONER INFORMATION FULL NAME Any Other Names Used address: (Provide if you prefer to receive information via ) Social Security No. / / Date of Birth 1 Current Address City State Zip Driver s License State No. Have you ever been convicted of a crime?* Offense County State Date Offense County State Date *To disclose additional criminal history, please provide those details on a separate sheet of paper and attach it to this form. Please provide all locations where you have resided for the past seven (7) years, starting with your current residence. City State Dates From: To: 1. / 2. / 3. / STATE LAW NOTICES Minnesota applicants or employees only: You have the right to request in writing from PreCheck, Inc., a complete and accurate written disclosure of the nature and scope of the report(s) requested by the Company. Place an X here for a disclosure to be sent to you. Oklahoma applicants or employees only: Mark an X here for a free copy of a consumer report if one is obtained by the Company. California applicants or employees only: Please mark this field to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law. California applicants or employees only: By marking an X in the designated field, you will receive and are acknowledging receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. New York applicants or employees only: If an investigative consumer report has been requested by the Company, the name and address of the consumer reporting agency furnishing the report can be found on the following disclosure and authorization document. You have the right to inspect and receive a copy of the investigative consumer report by directly contacting the consumer reporting agency, PreCheck, Inc. In connection with the Company s request for the preparation of a consumer report or investigative consumer report about you, the Company has provided you with a copy of Article 23-A of the New York Correction Law. Please mark this field to acknowledge receipt of a copy of Article 23-A:. Maine applicants or employees only: If you are applying for a position in the State of Maine, you may request and promptly receive from the consumer reporting agency copies of all investigative consumer reports about you requested by the Company. The name and address of the consumer reporting agency furnishing the report can be found on the following disclosure and authorization document. Massachusetts applicants or employees only: If you ask, you have the right to a copy of any background check report concerning you that the Company has ordered. You may contact the Consumer Reporting Agency for a Copy. Washington State applicants or employees only: You have the right, upon written request made within a reasonable period of time after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of the investigation we requested. I have read and understand the above information and assert that all information provided by me is true and accurate. Signature Date 1 The Age Discrimination in Employment Act of 1987 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age. This information is necessary for the proper processing of a consumer report. \ Nevada Private Investigator License # 1618 Ver. 0913

17 NICKLAUS CHILDREN S HOSPITAL #7430 PRACTITIONER DISCLOSURE & AUTHORIZATION FULL NAME Other Names Used Social Security No. / / Date of Birth / / Driver s License State: DL Number: DISCLOSURE REGARDING BACKGROUND INVESTIGATION [Nicklaus Children s Hospital] ( the Organization ) may obtain information about you from a consumer reporting agency made in connection with your application for appointment, employment, contract, or privileges. Thus, you may be the subject of a consumer report and/or an investigative consumer report which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding your criminal history, social security verification, motor vehicle records ( driving records ), verification of your education or employment history, or other types of verifications requested by the Organization. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by PreCheck, Inc., 3453 Las Palomas Rd. Alamogordo, NM 88310; 1(888)PreCheck [ ] or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing the Organization to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your employment, contract, privileges or appointment to the extent permitted by law. ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of consumer reports and/or investigative consumer reports by the Organization at any time after receipt of this authorization and throughout the term of my appointment, employment, contract or privileges, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance Organization to furnish any and all background information requested by PreCheck, Inc., 3453 Las Palomas Rd. Alamogordo, NM 88310; 1(888) PreCheck [ ] another outside organization acting on behalf of the Organization, and/or the Organization itself. I agree that a facsimile ( fax ), electronic or photographic copy of this Authorization shall be as valid as the original. By signing below, I confirm that I have read and understand the above information and that I provide my consent. Signature Date info@precheck.com ph: fax: (800) \ Nevada Private Investigator License # 1618 Ver. 0913

18 ANNUAL MEDICAL STAFF EDUCATION With my signature below, I attest that: I have received and reviewed the attached Annual Medical Staff Educational Manual. I will apply the content and principles of safe practices outlined in the Manual in my daily patient care activities as appropriate. Signature Date: Print Name Return Via FAX or Mail: Nicklaus Children s Hospital Medical Staff Services 3100 SW 62 Avenue, Miami, FL FAX:

19 ALLIED HEALTH PROFESSIONALS APPLICATION FEE INVOICE Applicant Name: $200 Application Fee DUE AND PAYABLE UPON RECEIPT. PAYMENT BY CHECK: Make check payable to: Nicklaus Children s Hospital Medical Staff Fund and return to: Nicklaus Children s Hospital Medical Staff Services 3100 SW 62 Avenue Miami, FL PAYMENT BY CREDIT CARD: Type of Card: Discover Visa Mastercard American Express Account #: Expiration. Date: CVV# Card Holder Name: P R I N T I authorize a payment in the amount of $200. Card Holder Signature: Nicklaus Children s Hospital / 3100 SW 62 Avenue / Miami, Florida / Phone: (305) / Fax: (305)

20 ORIENTATION ACKNOWLEDGEMENT FORM Applicant Name: I understand that Nicklaus Children's Hospital requires all applicants to attend a 3-hour orientation session once approved for credentials. I further understand that this orientation must be completed within the first six months from approval date in order to qualify for recredentialing. I understand that this is a specific qualification for appointment to the Medical Staff of Nicklaus Children's Hospital. Candidates who do not meet this requirement will be deemed ineligible for medical staff appointment, privileges shall terminate and the member shall not be entitled to a fair hearing. Signature: Date: H:\MENOCAL\DIRECTOR\FORMS\ORIENTATION ACKLOWLEDGEMENT 08/15.doc