INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF

Transcription

1 Dear: INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF Date: We are pleased to provide you with the enclosed Vanderbilt University Medical Center (VUMC) Initial Appointment Application for Professional Staff. This packet includes the application for Professional Staff membership and clinical privileges (as applicable). This one packet is used to expedite both the appointment of qualified applicants to the Medical Staff and enrollment with Vanderbilt Medical Group (VMG) contracted healthcare plans as applicable. The Medical Staff Bylaws and Rules & Regulations may be found at the following site: Please review these documents as you will be expected to abide by them and agree to do so by signing the Acknowledgement and Signature form located at the end of this application. Your application will be considered complete and ready for processing once all requested information has been received in the Provider Support Services (PSS) office and your Faculty Appointment (for billing providers) with the School of Medicine or School of Nursing has been verified. The submission of your application for membership does not automatically grant you Professional Staff membership and privileges. All applications must proceed through a verification and review process and must also be approved by the governing body. Once your completed, signed, and dated application is received in the Provider Support Services office, the credentialing process may begin. The credentialing process generally takes 90 days, however in order to reach this 90 day benchmark, we recommend the following: Provide Complete, Detailed Information Complete all areas of the application, providing as much detail as possible. Do not refer to documents such as your CV or resume. Incomplete applications cannot be processed and will be returned to the applicant for completion. If additional space is required to provide all of the information required, please submit additional files or pages with your application. Provide Accurate Information - The process may require less time if contact information, including accurate mailing addresses, telephone numbers, fax numbers and addresses is provided. Be prepared to help Your assistance may be required when, after several attempts, we are unable to obtain a response from a primary source. This application can only be completed electronically using Adobe Reader or Acrobat. Your application must be printed to be signed and submitted. Please do not sign or date documents until you submit your application. If your application is not approved by the Credentials Committee within 120 days from the date of signature your application will expire and a new application will have to be submitted, restarting the credentialing process. If we can further assist you in this process, please contact Provider Support Services at (615) To Submit your application: DO NOT RETURN VIA CAMPUS MAIL Ship USPS, FedEx, or UPS to: Scan and your application to PSS securely via Accellion: Provider Support Services provider.support.services@vanderbilt.edu st Avenue South, Room 4163 FAX to: Nashville, TN VUMC INIT PROF of 18

2 REQUIRED DOCUMENTS CHECKLIST The following documents are required for all practitioners in order to fully process your application. If any of the documents listed below are not available at the time of submission of your application, please submit your application with a note indicating when the documents will be submitted separately. NOTE: If you do not have a TN license, documentary evidence of submission of application must be provided prior to submitting this paperwork. Failure to do so will result in a delay in processing your application. Copy of advanced degree diploma (i.e., MSN, Ph.D., etc.) and any additional Advanced Training Certificates Copy of current Curriculum Vitae outlining education and practice history o All date entries must be complete and include From/To and MM/YY information. o Gaps in time greater than 30 days require a written explanation Copy of current (unexpired) U.S. Government issued photo ID (i.e., driver s license, passport) Copy of SIGNED social security card Copy of unexpired resuscitation certification (ACLS, BLS, Advanced Airway) as applicable Copy of current malpractice/professional liability insurance certificate. If clinical faculty and not receiving coverage through Vanderbilt Self Insurance Trust Fund, please provide evidence of professional liability coverage. Copy of current Federal DEA Registration Certificate (as applicable) Copy of DD214 (as applicable) Copy(ies) of Board Certification/Recertification (as applicable) Copy of NPI assignment letter Copy of faculty appointment letter for billing providers (facilitated by Department and separate from credentialing and privileging) Copy(ies) of Notice and Formulary signed by all Supervising Physicians or the designated Primary Supervising Physician (if applicable). Complete, signed, and dated Protocol Signature Sheet (as applicable) Questions in the sections below may require that you provide full details by submitting additional pages or files with your application. Additional pages or files should also be submitted with your application as necessary to provide complete information if there is not sufficient space within this form. Post Graduate Education and Training (Section G) Work History (See Section I) Professional Liability/Malpractice (See Section J) Licensure (Section L) Disclosure Information (See Section M) All sections of the Initial Application for Professional Staff must be completed. Sections that contain references to Curriculum Vitae (CV) only, or those left blank will be returned for completion. Sections which are not applicable must be marked N/A. NOTE: The faculty appointment process is separate from the credentialing and privileging process, and is facilitated by your department. Please contact them directly for information regarding faculty appointments. A faculty appointment must be granted prior to being considered for Professional Staff Membership. VUMC INIT PROF of 18

3 APPLICATION FOR INITIAL APPOINTMENT TO THE PROFESSIONAL STAFF A. PERSONAL INFORMATION Name should be listed as it appears on your license First Name Middle Name Last Name Suffix Social Security Number Date of Birth Degree Other Names by which you have been known Maiden Former Other Birthplace Birth City Birth State Birth Country Marital Status Single Married Divorced Widowed Partnered B. ADDITIONAL INFORMATION Spouse/Partner Name Copy of current (unexpired) US Government issued photo ID (i.e. driver license, passport) attached Yes No NPI Number: Copy of letter attached Yes No If No, documentation of immigrant status attached Yes No Do you have the legal right to work in the United States? Yes No Alien Status: Are you a US citizen? (If Yes, skip to section C) Yes Country of Citizenship: Permanent Resident Status: Alien Number: No C. MILITARY SERVICE/COAST GUARD: Branch Date Enlisted/Commissioned Discharge Type Discharge Date *If discharged please submit a copy of your DD214 Form with your application. D. OPTIONAL INFORMATION The information in this section is optional. If you choose not to respond, your application will not be affected in any way. If you respond, the information will be used for statistical reporting to entities such as State and Federal Government. Race/Ethnic Origin Gender Male Female English Only Language 1 Language 2 Yes No VUMC INIT PROF of 18

4 E. CONTACT INFORMATION Home Street Name and Number Home Phone Cell Phone Pager Office Street Name and Number Office Contact Phone FAX (615) Are you accepting new patients? Office Yes No Practice Coverage: Office Hours: Monday Friday Saturday Sunday After-Hours Covered By (Partners or Group Name) Emergency On-Call Number Is this an answering service? Yes No F. BOARD CERTIFICATION List all board certifications you possess and submit copies of original certificates with your application. First Board Certification Name of Board Specialty Certification Date Certificate Number Have you been recertified? Yes Second Board Certification Name of Board No Recertification date Specialty Certification Date Certificate Number Have you been recertified? Yes No Recertification date VUMC INIT PROF of 18

5 G. GRADUATE EDUCATION AND TRAINING Please provide a complete chronological history beginning with your highest level of education to present. For gaps in time greater than 30 days, a written explanation must be submitted with your application including the name(s) and contact information of individual(s) who can verify the information. Graduate Training Graduate/Professional School Degree Registrar/Verifying Office Name Phone FAX Attended From (MM/DD/YYYY): Additional Training 1 Graduate/Professional School To (MM/DD/YYYY): Degree Registrar/Verifying Office Name Phone FAX Attended From (MM/DD/YYYY): To (MM/DD/YYYY): VUMC INIT PROF of 18

6 H. HOSPITAL AND OTHER INSTITUTIONAL AFFILIATIONS List all hospital/health system affiliations where you have been employed, practiced, associated, or privileged for the purpose of providing patient care. DO NOT list affiliations that were part of your graduate training. Please mark your Primary Facility in the space provided. Local Hospitals Affiliation Dates (MM/DD/YYYY) Primary Facility 1. Centennial Medical Center From To Yes No 2. Gateway Medical Center From To Yes No 3. Jackson-Madison County General Hospital From To Yes No 4. Maury Regional Medical Center From To Yes No 5. Nashville General at Meharry From To Yes No 6. Parthenon Pavilion From To Yes No 7. St. Thomas Midtown From To Yes No 8. St. Thomas Rutherford From To Yes No 9. St. Thomas West From To Yes No 10. Skyline Medical Center From To Yes No 11. Southern Hills Medical Center From To Yes No 12. Summit Medical Center From To Yes No 13. Sumner Regional Medical Center From To Yes No 14. Tennessee Christian Medical Center From To Yes No 15. University Medical Center (Lebanon) From To Yes No 16. Vanderbilt University Medical Center From To Yes No 17. Vanderbilt Stallworth Rehabilitation Hospital From To Yes No 18. VA Medical Center (Nashville) From To Yes No 19. VA Medical Center (Murfreesboro) From To Yes No 20. Williamson Medical Center From To Yes No If you have current or past affiliations with hospitals other than those listed above, please list all of them below. Submit additional hospital affiliations with your application if necessary. Hospital Affiliation 1 Facility Name Med. Staff Office/Verifying Department Affiliated From (MM/DD/YYYY): To (MM/DD/YYYY): Is this your primary facility? Yes No Department Category Phone Fax VUMC INIT PROF of 18

7 Hospital Affiliation 2 Facility Name Med. Staff Office/Verifying Department Affiliated From (MM/DD/YYYY): To: (MM/DD/YYYY) Is this your primary facility? Yes No Department Category Phone FAX Hospital Affiliation 3 Facility Name Med. Staff Office/Verifying Department Affiliated From (MM/DD/YYYY): To (MM/DD/YYYY): Is this your primary facility? Yes No Department Category Phone FAX VUMC INIT PROF of 18

8 I. WORK HISTORY Please provide a complete chronological history beginning with your highest level of education to present. For gaps in time greater than 30 days, a written explanation must be submitted with your application including the name(s) and contact information of individual(s) who can verify the information. Work History 1 Employer Name Title/Position Contact Name Phone FAX Employed From (MM/DD/YYYY): Reason for Leaving To (MM/DD/YYYY): Work History 2 Employer Name Title/Position Contact Name Phone FAX Employed From (MM/DD/YYYY): To (MM/DD/YYYY): Reason for Leaving Work History 3 Employer Name Title/Position Contact Name VUMC INIT PROF of 18

9 Phone INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF FAX Employed From (MM/DD/YYYY): To (MM/DD/YYYY): Reason for Leaving Work History 4 Employer Name Title/Position Contact Name Phone Employed From (MM/DD/YYYY): FAX To (MM/DD/YYYY): Reason for Leaving Work History 5 Employer Name Title/Position Contact Name Phone FAX Employed From (MM/DD/YYYY): To (MM/DD/YYYY): Reason for Leaving J. PROFESSIONAL LIABILITY DISCLOSURE QUESTIONS AND INFORMATION Professional Liability Disclosure Questions Have any judgments or settlements ever been made against you or on your behalf in professional liability cases? Are any professional liability claims or cases currently pending? Yes* No Have you ever been denied professional liability insurance or has your policy ever been cancelled? *If the answer to any of the additional liability questions above is Yes, please submit full details with your application Yes* Yes* No No VUMC INIT PROF of 18

10 Professional Liability Coverage Information Beginning with current policy, list ALL of your professional liability carriers for the past 5 years for each facility including coverage during graduate training, as applicable. Current Liability Carrier Carrier Name Phone FAX Issue Date (MM/YYYY): End Date (MM/YYYY): Policy Number Coverage Amount each incident Annual Aggregate Amount Previous Liability Carrier 1 Carrier Name Phone FAX Issue Date (MM/YYYY): End Date (MM/YYYY): Policy Number Coverage Amount each incident Annual Aggregate Amount Previous Liability Carrier 2 Carrier Name Phone FAX Issue Date (MM/YYYY): End Date (MM/YYYY): Policy Number Coverage Amount each incident Annual Aggregate Amount Previous Liability Carrier 3 Carrier Name VUMC INIT PROF of 18

11 INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF Phone FAX Issue Date (MM/YYYY): End Date (MM/YYYY): Policy Number Coverage Amount each incident Annual Aggregate Amount K. PROFESSIONAL/PEER REFERENCES Provide the name and complete contact information for 3 healthcare providers as references from whom we may request specific written feedback. All references: Must be comparably licensed or an independently licensed practitioners you have worked with in the last two years No references may be related to you in any way Have personal knowledge of your clinical ability, ethical character, professional performance and ability to work cooperatively with others At least one reference must have had organizational responsibility for your performance (i.e., preceptor, department chair, section chief, etc.) Reference 1 Name Title/Position At what location/facility did you work with this person? Phone FAX Do or did they provide direct supervision? If Yes please provide dates below. Direct Observation Start Date (MM/YYYY): End Date (MM/YYYY): Yes No Reference 2 Name Title/Position At what location/facility did you work with this person? Phone FAX VUMC INIT PROF of 18

12 Do or did they provide direct supervision? If Yes please provide dates below. Yes No Direct Observation Start Date (MM/YYYY): End Date (MM/YYYY): Reference 3 Name Title/Position At what location/facility did you work with this person? Phone FAX Do or did they provide direct supervision? If Yes please provide dates below. Direct Observation Start Date (MM/YYYY): End Date (MM/YYYY): Yes No L. LICENSURE List all State Professional Licenses (including Tennessee) you currently hold or have held (APN, RN, etc.). If you are not currently licensed to practice in Tennessee, you must provide documentary evidence that you have applied for a Tennessee license. Failure to do so will delay the processing of your initial appointment application. License 1 Name (exactly as it appears on license) Issuing State Licensing Authority License Number Issue Date (MM/YYYY): Expiration Date (MM/YYYY): License 2 Name (exactly as it appears on license) Issuing State Licensing Authority License Number Issue Date (MM/YYYY): Expiration Date (MM/YYYY): License 3 Name (exactly as it appears on license) Issuing State Licensing Authority License Number Issue Date (MM/YYYY): Expiration Date (MM/YYYY): VUMC INIT PROF of 18

13 License 4 Name (exactly as it appears on license) Issuing State Licensing Authority License Number Issue Date (MM/YYYY): Expiration Date (MM/YYYY): Drug Enforcement Administration (DEA) Registration for Prescribers: Name (exactly as it appears on registration certificate) Registration Number Issue Date: Expiration Date: Please submit a copy of your DEA certification with your application. VUMC requires a fee paid full schedule (2, 2N, 3, 3N, 4, and 5) DEA registration in order to prescribe or write orders for scheduled drugs. If your DEA does not have a full schedule please submit a full explanation with your application. For Non-Prescribers Only: I do not prescribe or write orders for scheduled drugs. I acknowledge this is prohibited without first obtaining a full schedule DEA. Yes No VUMC INIT PROF of 18

14 M. DISCLOSURE INFORMATION 1. Have you, your license, or your participation with any of the entities below ever been investigated, involuntarily denied, revoked, suspended, not renewed, placed under probation, reprimanded, subjected to an adverse action or disciplinary action or otherwise limited or curtailed or have you voluntarily relinquished any of the items below in anticipation of disciplinary action or any of the previously listed actions occurring or are any of these actions pending? a. State Medical or other Professional License (including any out of state Professional License)? Yes* No b. DEA Registration or other applicable controlled substance registration? Yes* No c. Hospital or healthcare facility staff membership or privileges? Yes* No d. Medicare, Medicaid or other local, state, and/or federal government program participation? Yes* No e. HMO, PPO or other health plan participation? Yes* No 2. Has your standing with any of the following bodies been investigated, denied, revoked, suspended, reprimanded, limited, curtailed, not renewed, placed under probation, subjected to adverse or disciplinary action or is any such action pending? a. Professional ethics committee? Yes* No b. Regulatory Agency (CLIA, OSHA, etc.)? Yes* No c. Professional Malpractice Insurance Company? Yes* No d. Professional Training School or Program? Yes* No e. If others, please specify. N/A Yes* No 3. Have you ever been under investigation for, convicted of, arrested for, charged with, or pled to, any crime (other than minor traffic violations), including crimes involving child abuse/molestation? Yes* No 4. In addition to #3 above, have you ever been investigated for or found to be a perpetrator of child abuse, child sex abuse, or neglect by ANY local, state or federal agency, such as Child Protective Services? Yes* No 5. Have you been denied certification/recertification or been subject to any disciplinary action, (excluding action associated with lack of meeting attendance or non-payment of fees?) Yes* No 6. Have you ever been sanctioned by any other federal or state agency other than those specified above, including TennCare or Worker s Compensation Board? Yes* No 7. Have you ever opted out of Medicare? Yes* No 8. Have you ever been denied membership, renewal thereof, or been subject to any disciplinary action (excluding action associated with lack of attendance or non-payment of fees) in any healthcare organization or professional society, licensing or certifying board, whether federal, local, or state, or have proceedings by any of these been instituted? Yes* No *If the answer to any of the Disclosure Information questions above is Yes, please submit full details with your application. N. ABILITY TO PRACTICE MEDICINE 1. Are you able to safely perform all of the essential functions related to the specific clinical privileges you are requesting with or without reasonable accommodations? Yes No* *If NO, please submit full details with your application. 2. Do you currently or have you in the past engaged in the unlawful use of drugs, including the use of prescription drugs, not under the supervision of a licensed health care professional other than yourself? Yes* No *If Yes, please submit full details with your application. VUMC INIT PROF of 18

15 APPLICATION APPROVAL CONDITIONS: In making application for membership, I acknowledge that I will abide by the bylaws of the hospital(s), participating organization(s) and the medical ethics of the applicable licensing boards of Tennessee. I agree to be bound by the terms thereof if I am granted membership. As a condition of re-appointment, I agree that I will not participate in any form of fee splitting. I agree to abide by the medical staff bylaws and rules and regulations of the hospitals, clinics and institutions or other organizations to which I have applied for membership or requested professional staff privileges. I agree to abide by the patient bill of rights for those institutions for which I requested consideration. I understand and agree that, as an applicant to the participating organizations and as an applicant for professional staff membership, 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 believe that I am qualified to perform all procedures for which I have requested privileges. I have not requested privileges for any procedure for which I am not qualified. I pledge to maintain an ethical practice, to provide for continuous care for my patients, and to refrain from delegating the responsibility for any aspect of the care of my patients to any practitioner not qualified to undertake that responsibility. I pledge to participate in the educational activities provided by the facility, to abide by the bylaws, rules and regulations of the Medical Staff and the Governing Boards, to accept committee assignments as appropriate, to be subject to review as part of the quality assessment program, and agree that neither the facility to which I am applying or any member of the medical staff will be liable for any communication made during the credentialing process. I will avoid unwarranted publicity, dishonesty in any financial commercialism and to refuse acceptance in money, goods, in kind- or any inducement whatsoever from consultants, practitioners, makers of surgical appliances, instruments, and pharmaceuticals or others, and to make my fees commensurate with the service rendered and with the patient s rights, and to avoid discrediting my associates by taking unwarranted compensation. I further pledge to comply with all ethical standards in the Code of Conduct. ACKNOWLEDGEMENT AND SIGNATURE I attest that the information provided in or attached to this application is accurate and complete. I understand that a condition of this application is that any misrepresentation, misstatement, or omission from the application, whether intentional or not, may be cause for automatic and immediate rejection of this application and may result in the denial of membership and privileges and/or termination of any contract with any institution upon subsequent discovery of such misrepresentations, misstatements or omissions, and the hospital(s) or any other participation organization may immediately terminate my appointment, privileges, and/or membership. By my signature below, I further acknowledge and agree that I will promptly and fully report all information to the Credentials Committee(s) of each institution to which I am applying should any of the following occur: (1) any of the answers in the application change, (2) any situation arises which affects my ability to treat patients at any time after I have signed and dated this form, while my application is pending, or if I am appointed to the Medical Staff, Network or Foundation while I maintain membership. I agree that my completed application and information submitted with it to VUMC may be shared with Vanderbilt Health Affiliated Network Yes No Please indicate the Vanderbilt facilities at which you practice: VANDERBILT UNIVERSITY MEDICAL CENTER Vanderbilt Hospital & Clinic Vanderbilt Psychiatric Hospital Monroe Carell Jr. Children s Hospital at Vanderbilt Printed Name: Original Signature: Date: VUMC INIT PROF of 18

16 INVESTIGATION CONSENT AND AUTHORIZATION: By applying for appointment to the professional staff of a hospital, for membership or participation in any other organization to which I am applying, I hereby signify my willingness to appear for interviews with regard to my application, and I authorize representatives of the hospital, clinical staff, representatives of the institutions or other organizations to consult with administrators and members of the medical staffs of other hospitals, medical associations, institutions, state medical boards or professional licensing authorities with which I have been associated. I further authorize a criminal background check and contact with other entities to obtain information, including but not limited to coverage and claims information from past and present malpractice insurance carriers who may have information bearing on my professional competence, character and ethical qualifications. I hereby further consent to the release and inspection of all records and documents by and to any or all of the following: representatives of clinical staff, representatives of the institutions, the hospital, its medical staff, clinical staff, representatives of the institutions, third party payers, accrediting bodies and their authorized managed care designee. These records may include malpractice claims history, medical staff credentials files and any other pertinent records (including those at other hospitals with which I am affiliated) that may be material to an evaluation of my professional qualifications, clinical privileges requested, competency for enrollment into managed care health plans, ability to carry out my professional practice, as well as moral and ethical qualifications for membership and appointment to the professional staff of a hospital or clinic. I present this information as part of this credentialing process in the expectation that its confidentiality and privacy will be preserved, and this information will be released or disclosed only as part of current and future credentialing, peer review and quality assurance processes, to the extent possible under State and Federal law. WAIVER OF LIABILITY: I hereby release from liability all representatives of a Centralized Credentials Verification Service, Vanderbilt University, its trustees, employees and officers, participating organizations, the hospital, clinical staff and representatives of the institution for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications. I hereby release from liability any and all individuals and organizations who provide information to a hospital or its medical staff, clinical staff, representatives of the institutions and participating organizations, Vanderbilt University or the Centralized Credentials Verification, in good faith and without malice, concerning my professional competence, ethics, character and other qualifications for medical association, membership or participation in designated organizations for staff appointment and clinical privileges, and I hereby consent to release of such information. INFORMATION RELEASE: I hereby further authorize and consent to the release of information and documents by the releasing institution(s) to other health care institutions, a Centralized Credentials Verification Service, or providers as long as such release of information is done in good faith and without malice. I hereby release from liability the releasing institution(s), its trustees, its employees, agents, officers, servants, faculty and staff in connection with sum provision of information. APPLICATION PHOTOCOPY APPROVAL: By applying to any hospital or organization for privileges, I authorize the institution(s) checked in the previous section to provide any other hospital(s), managed care organization(s) or other organizations a copy of this application and agree that a photocopy of this application or a fax copy of this application and release shall be as sufficient as though I had duly executed the same in my own handwriting. Printed Name: Original Signature Date: VUMC INIT PROF of 18

17 APPOINTMENT/PROTOCOL APPROVAL FORM Advanced Practice Registered Nurse/Physician Assistant APPOINTMENT/PROTOCOL APPROVAL FORM The accompanying signatures serve to recommend the appointment of as in the Department of for a period not to exceed two years commencing. Practice location: If applicable, (APRN/ PA) the accompanying signatures serve to confirm the attached list of evidenced based practice protocols/guidelines have been reviewed and approved by both the practitioner and supervising physician and are consistent with the practitioner s scope of practice/delineation of privileges and specific to the patient population. [ Protocol review and revision will occur every two years consistent with the reappointment process. SUPERVISING PHYSICIAN(S) (Name/Title) (Name/Title) (Signature) (Date) (Signature) (Date) APRN/PA Applicant: (Name/Title) (Signature) (Date) Chief of Service/Division: (Name/ Department) (Signature) (Date) VUMC INIT PROF of 18

18 PROVIDER ACKNOWLEDGEMENT STATEMENT Dear Provider: In accordance with Regulation 42 CR , HCFA requires that Vanderbilt obtain a Provider Acknowledgement Statement at the time of appointment. When signed, the statement is an acknowledgement that you are aware of Medicare regulations pertaining to physician attestation for hospital billings to Medicare. Please sign the statement below and return it to Provider Support Services with your application. These federal regulations require that the statement be part of your file prior to patient contact. Thank you for your cooperation. C. Wright Pinson, MBA, MD Deputy Vice Chancellor for Health Affairs CEO of the Hospitals and Clinics Vanderbilt University Medical Center Notice to Physicians: Medicare payment to hospitals is based in part on each patient's principal and secondary diagnoses and the major procedures performed on the patient, as attested to by the patient's attending physician by virtue of his or her signature in the medical record. Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal funds, may be subject to fine, imprisonment, or civil penalty under applicable Federal laws. Provider s Name (Please print or type) Signature Provider NPI No. (MUST be included) Date VUMC INIT PROF of 18

19 ELEMENTS OF INFORMED CONSENT 1. The nature of the patient s condition; 2. The proposed surgical, medical or radiological procedure and the operative site (if applicable) 3. The benefits and risks of the proposed procedure(s) stating the frequently occurring and significant risks, using the phrase, including but not limited to: and state, it is not possible to guarantee results ; 4. Explain treatment alternatives, including no treatment; 5. The consequences of no treatment; 6. Who will be performing the procedure and a description of the role of residents or others who may perform significant portions of the procedure; 7. The risks of anesthesia; 8. Potential blood/blood product transfusions 9. The patient or patient s legal representative should be given the opportunity to ask questions and receive additional information as requested; 10. The patient must be able to teach back : Describe in his/her own words the procedure, the risks and benefits, and what parts of his/her body will be involved;

20 Vanderbilt Medical Group Designation of Agent For Preparation and Submission of Forms, Applications and Check Authorization I, hereby authorize the Director of the Vanderbilt Medical Group Business Office (or his/her duly appointed designee): 1. To act as a proxy agent for me in the preparation, signature when required, and submission of applications, authorization agreements and insurance forms. This proxy status is inclusive of creating a user account and logging into internet-based systems of the Centers for Medicare and Medicaid Services (CMS) Identity and Access Management (I&A) System, National Plan and Provider Enumeration System (NPPES), and Provider Enrollment, Chain and Ownership System (PECOS). 2. To complete CMS Meaningful Use Attestation when qualified as an Eligible Professional, and when appropriate certified EHR objectives and measures are met. I also consent to reporting of provider and practice level data for designated clinical quality measures as part of the CMS Physician Quality Reporting System (PQRS). 3. To release my signature electronically or by facsimile on all documents and applications necessary for my enrollment into managed care health plans, with which VMG has a provider contract. I understand that release of my signature in this way shall be as sufficient as though I had duly executed the same in my own handwriting. I am given the following assurances by the Director of the Vanderbilt Medical Group Business Office (or his/her duly appointed designee): a. Insurance claim forms will be prepared only in those instances where I have submitted an appropriately documented charge as supported in the medical record. b. That all insurance proceeds made payable to me will be entered in my revenue accounts. 4. Through the Payments Section of the Vanderbilt Medical Group to restrictively endorse and deposit to an Account of Vanderbilt University all checks made payable to me received as payment of fees for professional services rendered by me to or on behalf of my patients pursuant to provisions of the Vanderbilt Medical Group Bylaws. This authority will continue until the same is revoked in writing. Signature Approval Date

21 VANDERBILT MEDICAL GROUP PARTICIPATION AGREEMENT WHEREAS, the undersigned Participating Member desires to engage in the group practice of rendering professional services in the care of patients as a member of the Vanderbilt Medical Group (VMG), and VMG desires that Participating Member engage in professional practice as a member of the VMG; NOW, THEREFORE, in consideration of Participating Member s employment by Vanderbilt University and participation in the VMG, it is agreed as follows: 1. Bylaws. Participating Member agrees that he/she has received, read and will abide by the Bylaws of the VMG, which bylaws are hereby incorporated by reference and made a part of this Participation Agreement. 2. Group Practice. Participating Member shall not engage in any professional activities in the care of patients except in accordance with the standards and conditions set forth in the Bylaws of the VMG and/or as established by the Board of Directors of the VMG. 3. Fees. Reimbursement and fees for all of the professional patient care services rendered by Participating Member shall be endorsed over to and shall be the property of Vanderbilt University. 4. Health Plan Contracts. Participating Member shall enroll in any and all health insurance plans as participating member of the VMG, and may not contract with, or opt out of, any health insurance plan, including but not limited to the Medicare program, except as a member of and together with the VMG. Agreed to and Accepted by: Participating Member (Signature) (Printed Name) (Department Chairman Signature) (Printed Name) Department VANDERBILT UNIVERSITY by and through its SCHOOL OF MEDICINE By: Title: (Printed Name) Date:

22 PROFESSIONAL LIABILITY APPLICATION 1. Name of Physician 2. Degree Code - For Risk Management Use Only 3. Effective Date 4. SSN or Employee ID # 5. Department 6. Division 7. Specialty 8. Physician Status: Fellow Faculty Fellow with Faculty Appointment 9. Full Time: Part Time: Clinical Hours Per Week * Clinical hours must include time devoted to inpatient rotations, scheduled clinics, participation on consult service, supervision of fellows & residents in their care and clinical responsibilities and must include on call time, including nights, weekends, and holidays. 10. Please circle time to Veterans Administration (VA): 0 1/8 2/8 3/8 4/8 5/8 6/8 7/8 8/8 11. Check all that apply. Surgical Specialties Bariatric Surgery Orthodontics/Dentistry Pediatric Surgery (including other weight Ophthalmology / Surgical Plastic Surgery reducing procedures) Procedures Podiatry (Procedures) Cardiac Surgery Orthopedic Surgery Surgical Oncology Colon/Rectal Surgery (other than Trauma) Thoracic Surgery General Surgery Otolaryngology/Plastics Trauma Gynecology Surgery Otolaryngology Head & Neck Urology Neurosurgery Surgery Vascular Surgery OB Delivery Otolaryngology (all types OTHER Other (please explain) Oral Surgery than major Head & Neck Surgery & Plastics) Other Specialties Allergy Medicine or Pediatric Specialty - No Procedures (Diabetes, Endocrinology, Hematology/Oncology, Anesthesiology Infectious Disease, Rheumatology, Gastroenterology, Nephrology, Child Development, etc) Cardiology / No Procedures Neonatology Psychology Cardiology / Procedures (see Neurology Pulmonary Medicine/Critical Care procedure list below) Nutrition Do you attend in ICU? (please circle) Clinical Pharmacology OB / GYN Outpatient or Clinic YES or NO CRNA Visits Only Radiation Oncology Dermatology / General Occupational Medicine Radiology Procedures / Interventional Dermatology / Procedures Ophthalmology (No surgery) (includes dye injections & Nuclear Medicine) ED (Fast Track Only) Optometry Radiology, Diagnostic / No Procedures Emergency Medicine Pathology / No Procedures Research - Patient Oriented, but NO patient General Internal Medicine Pathology / Procedures care, no resident supervision of any kind General / Medicine Pediatric Physical Medicine & Rehab / Other (please explain) Medicine or Pediatric Specialty - Sports Medicine Procedures (see procedure list Podiatry / No Procedures below) - Diabetes, Endocrinology, Hematology / Oncology, Infectious Psychiatry Disease, Rheumatology, Gastroenterology 12. If not in Anesthesia, critical care, or a surgical discipline please review the following lists and check all that apply. If you perform or may be called upon to perform or supervise any of these procedures at least once a year, we need to know for appropriate insurance coverage. Please check the following medical techniques or procedures you perform: Angiography Arteriography Bone Marrow Harvest Bronchoscopy (rigid or flexible) Catheterization-Arterial, cardiac, or diagnostic, but does not include: 1. Occasional emergency insertion of pulmonary wedge, Needle Biopsy Endoscopy ERCP (Endoscopic retrograde cholanglopancreatogarphy) Lasers - used in therapy Lympangiography Mohs Surgery Myelography pressure recording catheters. Pneumatic or mechanical esophageal dilation 2. Urethral Catheterization Radiopaque dye injections into blood vessels, lymphatics, sinus tracts 3. Umbilical cord catheterization for diagnostic purposes or for and fistulae monitoring blood gases in newborns receiving oxygen. Transesophageal Echocardiography Colonoscopy Other Dermatology Faculty - Advanced Dermalogic Surgery Budget Number to be charged: (Please provide only one budget number.) Physician/CRNA Signature & Date Department Administration Signature & Date Verifying Completion of Form 04/03/07

23 PROFESSIONAL STAFF BILLING APPLICATION Name: Department: Title: Nurse Practitioner Physician s Assistant Psychological Examiner Genetics Counselor Certified Nurse Midwife PhD Psychologist Licensed Therapist Other The following questions are to be answered by Department/Division Employing Applicant: 1. What is the employee s academic appointment? SON SOM (Faculty appointment letter must be attached with this application) 2. What is the home department number of the employee? Job Code? 3. Salary Responsible Entity: Hospital Department/Division SON Owned 4. Department Business Officer and/or Billing Manager (Name contact for information and notification) Name: Title: Phone#: (615) Please list the funding sources of the employee s salary [should match with PAF]: Center # Center Name % Center # Center Name % Center # Center Name % If grant funded, explain: 6. Please indicate the following: Site(s) of service: Supervising Physician: Mapped to Epic Dept # and Center # Responsible party for completing income distribution form (IDF) Name: Title: Phone#: 7. Indicate if this will be a new position or replacement position. New Replacement 8. FTE Status: Chairman s Signature Date Billing Committee: Approved Rejected Committee Chair Signature Date Submit Application with attached PAF and Faculty Appointment Letter to: Office of Advanced Practice For questions call or Vanderbilt University Medical Center (May fax copy for initial review to , Suite S-2406 must have original on file for approval) Medical Center North Nashville, TN

24 Provider Support Services 4163 Village at Vanderbilt NASHVILLE, TN 37232

25 DO NOT DUPLICATE BLUECROSS BLUESHIELD OF TENNESSEE, Inc. (BCBST) PRACTITIONER PRE - APPLICATION (Includes MDs, Physician Extenders and Health Care Practitioners) Completion and acceptance of this Pre-Application by BlueCross BlueShield of Tennessee, Inc. is not a guarantee of Network Participation. Appeals related to this Pre-Application will be governed by BlueCross BlueShield of Tennessee, Inc. policies and procedures. Pre-Application must be completed in its entirety, including the Professional History section. Please complete carefully and legibly. Name,,, Last First Mid. Int. Degree Group Practice Name: Vanderbilt Medical Group Primary Office Location: 3601 The Vanderbilt Clinic Phone # ( ) (615) (Please list all other locations, City, State, Zip and County on a separate sheet of paper and attach to pre-application.) City: Nashville State: TN Zip: County (TN or Contiguous) Davidson Social Security Number: Date of Birth: Gender: M or F Primary Specialty: Secondary Specialty: Licensure Number: State Issuing License: TN DEA Certification Number: APN Licensure Number (CRNAs, NMWs, NPs): RN Licensure Number (CRNAa, NMWs, NPs): Name of Medical/Professional School(s) attended: Date of Graduation: / / MM / DD / YY : Office Contact Name and Title Marian R. Gardner, Manager Payer Enrollment CHECK NETWORKS APPLYING FOR: Blue Network C Blue Network P Blue Network S Blue Network K BlueCare TennCare SM Select BPN Provider Responsibilities 1) Do you have malpractice insurance coverage for a minimum of at least $1,000, per claim and $3,000, in the aggregate? Yes No a) If the answer is No, do you only work for the State of Tennessee? 2) Do you have admitting privileges with a BCBST network hospital? If Yes, at which hospital(s) Vanderbilt University Hospital a) If No, please list BCBST practitioner providing your provision for coverage and BCBST hospitals where he/she has admitting privileges b) If you are a nurse practitioner, physician assistant or certified nurse midwife, please enter your preceptors name and BCBST network hospital where he/she admits: Professional History Please read the following questions carefully. No Yes 1. ( ) ( ) Are you currently practicing with an invalid or expired license? 2. ( ) ( ) Is your license to practice restricted? 3. ( ) ( ) a. Has your medical license been revoked or not renewed (a license "revocation") by any jurisdiction within the last two (2) years, for cause, or have you surrendered your license to avoid such a revocation? b. If answer to 3.a. is yes, please indicate date license was re-issued. ( ) ( ) c. Do you have a license revocation action pending or initiated against you? 4. ( ) ( ) a. Has your Drug Enforcement Administration Certificate(DEA) or Controlled Dangerous Substances Certificate(CDS) been revoked, or not renewed (a "revocation") by any jurisdiction within the last two (2) years, for cause, or surrendered to avoid imposition of such revocation? b. If yes, please indicate date(s) DEA and/or CDS certificates was/were re-issued. DEA CDS ( ) ( ) c. Do you have DEA or CDS certificate revocation actions pending or initiated against you? 5. ( ) ( ) Have you been convicted of fraud, felony, or any offense involving moral turpitude by any jurisdiction within the last two (2) years, or is such action pending or been initiated against you? 6. ( ) ( ) Are you currently sanctioned by Medicare or Medicaid? (e.g. excluded from participation in Medicare or Medicaid Program(s)) CERTIFICATION OF PROFESSIONAL HISTORY and PROVIDER RESPONSIBILITIES As a condition of my participation in any BCBST product network, I agree to maintain general liability insurance coverage with reasonable limits and worker s compensation insurance coverage in accordance with applicable state law. Further, I agree to maintain such coverage continuously while participating in any BCBST product network, and will provide acceptable proof of such coverage to BCBST upon request. I, the undersigned practitioner, certify that the above and any additional information provided is complete, accurate, and true. I acknowledge that falsification, inaccuracy, or failure to fully disclose any information requested is grounds for rejection of practitioner s application for any BCBST Provider Networks. I hereby authorize BCBST to query the National Practitioner Data Bank (NPDB) and the Healthcare Integrity and Protection Data Bank (HIPDB) and further release BCBST from any and all liability arising from querying and reporting to the HIPDB as required by 45 CFR Part 61, except to the extent BCBST has actual knowledge of the falsity of the reported information. I further agree that any dispute relating to or arising in connection with this application must be resolved in accordance with applicable BCBST policies and procedures. Date: Signature: Please print name of Provider Relations Representative submitting Pre-Application: Date: For BCBST Use Only: PreApp Rev 13 12/15/04

26 IMPORTANT NOTICE REGARDING IMMUNIZATIONS EFFECTIVE IMMEDIATELY, ALL VANDERBILT EMPLOYED PRACTITIONERS WILL BE REQUIRED TO BE COMPLIANT WITH VANDERBILT MEDICAL CENTER IMMUNIZATIONS PROGRAM AND TUBERCULIN (TB) SKIN TESTING AT THE TIME OF THEIR INITIAL APPOINTMENT OR REAPPOINTMENT. Faculty: You can check your record of compliance on the Faculty Orientation and Training Office website at Staff: Your supervisor can check your compliance status on MyVandy by viewing the Record of Compliance in Occupational Health report. any additional questions to If you prefer to contact Occupational Health by phone, please call

27 Pre-Arrival Immunization and Screening Form for Newly Credentialed Faculty Please return completed form and documentation by fax to: Vanderbilt Occupational Health Clinic Fax # (615) Phone # (615) The Occupational Health Clinic would like to welcome you to Vanderbilt. Our clinic is dedicated to protecting you and your patients from infectious diseases. To meet the requirements of the Medical Center Policies and OSHA, you will need documentation for the following immunizations and/or tests before beginning work at Vanderbilt. This worksheet should be completed and documentation of all immunizations and tests must be attached. For explanation of requirements, see reverse side. Name: SS#: - - Date of Birth: Department: Anticipated Start Date: TUBERCULOSIS: Two TB skin tests are required within 12 months prior to your start date at Vanderbilt. One of these must be within 3 months of the start date: Date #1: / / Result (+) (-) Date #2: / / Result (+) (-) If you have a previous positive skin test (>10mm indurations) or a positive IGRA (e.g QuantiFERON or T-spot): Date of first positive TB skin test: / / Dates of INH therapy, if taken: Attach the official report of a chest x-ray taken within the past 6 months. DISEASES (For detailed immunization requirements, see reverse side) IMMUNIZATION DATES (remember to attach documentation) Antibody Tests (remember to attach documentation) Date Result Hepatitis B (1) (2) (3) (+) (-) Document any additional hepatitis B shots here: Varicella/chickenpox (1) (2) (+) (-) MMR (1) (2) (+) (-) Measles (Rubeola or red measles) (1) (2) (+) (-) Mumps (1) (+) (-) Rubella (German measles) (1) (+) (-) Tetanus/Diphtheria (optional) Tetanus/Diphtheria/Pertussis (optional) Last booster: I have worked at Vanderbilt Medical Center previously please review my employee immunization records. I have received immunizations as a patient or student at Vanderbilt and give Occupational Health my permission to review my medical record for them. Signature required: Date:

28 VUMC IMMUNIZATION/SCREENING REQUIREMENTS HEPATITIS B: If you have the potential to come in contact with human blood or body fluids as part of your employment here, you must document either A. A completed series of 3 hepatitis B vaccines, or B. A hepatitis B vaccine series in progress, or C. Laboratory evidence of immunity to hepatitis B, or D. Informed refusal of the vaccine (by signing declination form at the Vanderbilt Occupational Health Clinic.) VARICELLA (chickenpox): Written documentation of a varicella immunity test drawn from a reputable laboratory (date and result), or documentation of two doses of varicella vaccine. MMR Measles (rubeola): If born on or after 1/1/1957, written documentation of either A. Two (2) live measles (rubeola) vaccines given at least one month apart, after the first birthday, or B. One (1) measles/mumps/rubella (MMR) vaccine since age 18, or C. Laboratory evidence of immunity to rubeola (date and result,) or D. Documentation of physician-diagnosed rubeola infection. Mumps: If born on or after 1/1/1957, written documentation of either A. One dose of live mumps after the first birthday, or B. Laboratory evidence of immunity to mumps (date and result,) or C. Documentation of physician-diagnosed mumps infection. Rubella (German measles): (Regardless of birthdate) A. Written documentation or laboratory evidence of immunity to rubella, with date and result, or B. Documentation of an MMR vaccine or a rubella vaccine after the first birthday TETANUS/DIPHTHERIA/PERTUSSIS: Documentation of a tetanus/diphtheria booster within past 10 years. Td now has acellular pertussis component which is recommended for healthcare workers and anyone who has close contact with an infant. (Optional) TUBERCULOSIS: A. Written documentation of either 2 negative TB skin tests within the past 12 months with the most recent being within the past 3 months, or B. If you have a prior positive skin test (or positive quantiferon test,) you must have a chest x-ray within 6 months prior to beginning work at Vanderbilt. NOTE: If you have had BCG vaccine you are still required to undergo TB skin testing, unless you have also had a previous positive skin test or quantiferon test.

29 STATE OF TENNESSEE DEPARTMENT OF HEALTH HEALTH RELATED BOARDS TENNESSEE BOARD OF NURSING 665 MAINSTREAM DRIVE NASHVILLE, TENNESSEE (800) , ext or (615) ADVANCED PRACTICE NURSE NOTICE AND FORMULARY Advanced Practice Nurse Name *Advanced Practice Nurse DEA Number TN Advanced Practice Nurse License Number TN or Multistate Registered Nurse License Number Delete Supervising Physician(s): Delete Practice/Clinic(s): (If more space is needed for deletions please attach additional sheets) Check the category of legend drugs the APN is authorized to prescribe: (*must have own DEA number to prescribe Schedule s II-V) Non controlled legend drugs Controlled legend drugs including: Schedule II Schedule III Schedule IV Schedule V Initial or adding a new practice site(s) & Supervising Physician(s): Name of Practice/Clinic Name of Practice/Clinic Site Site Supervising Physician Printed Name Supervising Physician Printed Name Supervising Physician Signature Supervising Physician Signature DEA Number DEA Number MD/DO License Number MD/DO License Number Attestation I, attest that the information contained in this application is true and correct. Print Name Return original to: Tennessee Board of Nursing 665 Mainstream Drive Nashville, TN Signature of Advanced Practice Nurse/Date NOTE: Mandatory Practitioner Profile will be updated based on receipt of this Notice & Formulary PH #3625 (REV. 9/14) This page may be duplicated RDA #10137