APPLICATION FOR APPOINTMENT TO THE MEDICAL STAFF

Transcription

1 APPLICATION FOR APPOINTMENT TO THE MEDICAL STAFF Please print clearly. 1. Name of Applicant SSN: 2. Office Address Telephone Fax 3. Residence Address: Telephone address: Cell 4. Date of Birth: Place of Birth: Citizenship: 5. Undergraduate Institution _ Education Full Address Dates Attended Degree 6. Medical/Dental Institution_ Education Full Address Dates Attended Degree 7. Internship Institution Full Address Director Fax Dates Attended Type 8. Residency Institution Program(s) Full Address Dates Attended Specialty Department Chairperson Fax 9. Fellowships Institution Preceptorships Assistantships Full Address Dates Attended Specialty Director_ Fax

2 10. List in chronological order all medical/surgical experiences subsequent to your training (military service, private practice, public health service, teaching, research, etc.) with consecutive dates (month/year), locations (full addresses with zip codes) and names of responsible superiors (if additional space is required, attach separate sheet of paper.) 11. List all present and previous hospital affiliations (if additional space is required, attach separate sheet.) a) Name Dates Full Address Clinical Privileges/Membership Status Department Chairperson/Chief of Service b) Name Dates Full Address Clinical Privileges/Membership Status Department Chairperson/Chief of Service 12. List all medical practitioners with whom you were previously associated and the dates of such associations (if additional space is required, attach separate sheet). a) Name Dates Full Address b) Name Dates Full Address 13. List all medical publications. If desired, attach bibliography. If additional space is required, attach separate sheet. (May attach to CV) 14. List any special awards, honors, offices held, achievements, appointments, etc. (May attach to CV) 15. List all past and present professional fellowships, memberships, and societies (local, state and national) with dates. (May attach to CV) 16. List all medical references (no current partners or relatives) from two or more physicians who have worked extensively with you, one of whom has been responsible for supervision of your performance (e.g. Department Chief, Service Chief, training program director): Name Name Name Address Address Address City State Zip City State Zip City State Zip Ph Fax Ph Fax Ph Fax

3 17. Kansas State Medical/Dental License: Number Date Issued All other past/present state licenses: State License No. Issued State License No. Issued State License No. Issued State License No. Issued 18. Drug Enforcement Administration (DEA) Number Date Issued 19. National Provider Identifier (NPI) 20. If foreign educated: ECFMG Number Date exam passed 21. Specialty Certification: Date FLEX exam passed a) Are you certified by a specialty board? Yes No If yes, indicate the name of board and date of certification: b) Have you applied to a specialty board for examination? Yes No If yes, give the name of the board, the date of application, and date of examination: c) Are you board eligible? Yes No If yes, indicate the year when eligibility status will terminate under the specific board s rules: 22. List your current professional liability insurance carrier (company name and complete address): Insurance Co. Name Complete Address Policy Effective Dates: Include original inception date Limits of coverage Policy # List all previous professional liability insurance carriers the name and complete address, effective dates of policy, and any malpractice suits or claims brought against you including resolution of each. Continue on separate sheet if needed. Carrier Address Effective Dates Policy # Suits/Claims Resolution: Carrier Address Effective Dates Policy # Suits/Claims Resolution:

4 IF ANY OF THE FOLLOWING QUESTIONS (23-29, 35 & 36) ARE ANSWERED YES, GIVE FULL DETAILS IN A SEPARATE LETTER: 23. Has there ever been a challenge, denial, or voluntary or involuntary revocation, suspension, reduction, limitation, probation, non-renewal, or relinquishment of your: a) License to practice in any state or country? Yes No b) Narcotic registration? Yes No c) Membership in any professional organization? Yes No d) Board certification or eligibility? Yes No e) Faculty membership at any professional school? Yes No f) Staff membership at any health care facility? Yes No g) Clinical privileges at any health care facility? Yes No h) Professional liability insurance coverage? Yes No 24. Have you ever been on a leave of absence, formal or informal, either personal or professional, or suspended from any training programs, residencies, hospitals or facilities? If so, please attach information and an individual who can validate this information. Yes No 25. Have you ever been convicted of a felony crime? (List all felony crimes of which you have been convicted) or class A misdemeanor? This includes a diversion or plea to a felony or class A misdemeanor. Yes No 26. Have you ever been a habitual user, addicted to the use of, or suspected of, or charged with any crime relating to the use, possession or sale of barbiturates, alcohol or other drugs or controlled illegal substances? Yes No 27. Have you ever taken part in any counseling or treatment programs for abuse, addiction of drugs, alcohol or any other Illegal substances? Yes No 28. Have any malpractice lawsuits or claims been brought against you relating to any professional practice? (List any pending or previous malpractice claims or actions on the enclosed Suite/Settlement Form. Attach additional pages if needed. The resolution of each must be included.) Yes No 29. Have you been convicted of a criminal offense related to the provision of healthcare items or services resulting in your debarment, exclusion or suspension from participation in State or Federal healthcare programs? Yes No If so, please explain: 30. Will you be associated with another practitioner? Yes No If so, please list name(s): 31. Membership category desired: Active Admitting Active Non-Admitting Consulting 32. Department membership desired: Anesthesia Emergency Medicine Family Practice Medicine OB/GYN Pathology Pediatrics Radiology Surgery

5 33. Log of procedures enclosed? Yes No 34. Have you/do you suffer from any physical or mental health impairment that would affect your ability to care for patients or perform the privileges requested? Yes No 35. Have you been counseled/treated for anger or disruptive behavior in the last 10 years? Yes No 36. Please attach a copy of your photo ID (Driver s License or Current Passport), Certificates (Medical School, Residency, Internship, Etc.). Signature: Date: This completed application form should be mailed to: Medical Staff Office Lawrence Memorial Hospital 325 Maine Street, Lawrence, KS PH: FAX:

6 AUTHORIZATION AND AGREEMENT I fully understand that any significant misstatements in or omissions from this application/reapplication constitute cause for denial of appointment/reappointment or cause for summary dismissal from the Medical Staff. All information submitted by me in this application/reapplication is true and complete to my best knowledge and belief. In making this application/reapplication for appointment/reappointment to the Medical Staff of Lawrence Memorial Hospital, I acknowledge that I have read the Bylaws, Rules and Regulations of the Medical Staff of this Hospital, and that I am familiar with the principles and standards of the Center for Medicare and Medicaid Services, Joint Commission on Accreditation of Healthcare Organizations and the principles, standards and ethics of the national, state and local associations that apply to and govern my specialty and/ or profession, and I agree to be bound by the terms thereof if I am granted membership or clinical privileges, and I further agree to be bound by the terms thereof without regard to whether or not I am granted membership of clinical privileges in all matters relating to the consideration of my application/re-application for appointment/reappointment to the Medical Staff, and I further agree to abide by such Hospital and staff Rules and Regulations as may be from time to time enacted. By applying for appointment/reappointment to the Medical Staff I hereby signify my willingness to appear for the interviews in regard to my application/reapplication, authorize the Hospital, its Medical Staff and their representatives to consult with administrators and members of medical staffs of other hospitals or institutions with which I have been associated and with others, including past and present malpractice carriers, who may have information bearing on my professional competence, health, character and ethical qualifications. I hereby further consent to the inspection by the Hospital, its Medical Staff and its representatives of all records and documents, including medical records, at other hospitals, treating physicians and psychiatrists on an on-going basis. I further agree to provide the Hospital at their request any appropriate authorization for the release of the aforementioned information, that may be material to an evaluation of my professional qualifications and competence to carry out the clinical privileges requested as well as my moral and ethical qualifications for staff membership. I hereby release from any liability any and all individuals and organizations who provide information to the Hospital, or its Medical Staff, in good faith and without malice concerning my professional competence, ethics, character and other qualifications for staff appointment/reappointment and clinical privileges, and I hereby consent to the release of such information. I further authorize and instruct my medical malpractice insurance provider to release information to the Hospital regarding my coverage and to notify the Hospital in the event my insurance is canceled or not renewed. I hereby further authorize and consent to the release of information by this Hospital, or its Medical Staff, to other hospitals, medical associations and other interested persons on request regarding any information the Hospital and the Medical Staff may have concerning me as long as such release of information is done in good faith and without malice, and I hereby release from liability this Hospital and its staff for so doing. I accept/acknowledge the provision in the Bylaws regarding release and/or immunity from civil liability. I understand and agree that I, as an applicant/reapplicant for Medical Staff membership and/or privileges, 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 understand that I will be notified in writing of any information obtained in my credentialing/recredentialing process that varies substantially from information provided by me. I understand that I may at any time request information as to the status of my credentialing/recredentialing application. I will not participate in any form of fee-splitting. Moreover, I pledge myself to shun unwarranted publicity, dishonest money-seeking, and commercialism; to refuse money trades with consultants, practitioners, makers of surgical appliances and optical instruments, or others; to teach the patient his financial duty to the physician and to expect the practitioner to obtain his compensation directly from the patient; 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 hereby pledge to provide my patients with continuous care. I affirm my commitment to protect the confidentiality of health information that comes into my possession during my association with Lawrence Memorial Hospital. I will not at any time during or after my affiliation with LMH disclose any patient information to any person whatsoever or permit any person to use patient information, other than as necessary for patient care in the course of my affiliation. When patient information must be discussed with other health care practitioners in the course of my work, I will use discretion to assure that others not involved in the patient s care cannot overhear such conversations. I understand my responsibilities regarding my information systems password usage. I have not requested privileges for any procedures for which I am not qualified. Furthermore, I realize that certification by a board does not necessarily qualify me to perform certain procedures. I believe that I am qualified to perform all procedures for which I have requested privileges. Release and Immunity By applying for appointment and clinical privileges, I accept the following conditions regardless of whether or not I am granted appointment or privileges, and intend to be legally bound thereby. These conditions shall remain in effect for the duration of any term of appointment I may be granted: (1) I agree not to sue the hospital, the medical staff or anyone acting by and/or for the hospital and its medical staff for any matter relating to this application for appointment or clinical privileges, the evaluation of my qualifications or any matter related to appointment, reappointment or clinical privileges; and (2) I extend absolute immunity to the hospital and/or its medical staff for all matters relating to appointment, reappointment and clinical privileges or the evaluation my qualifications for the same. Signature of Applicant/Reapplicant Printed Name Date

7 HEALTHCARE EMPLOYMENT SCREENING DISCLOSURE AND RELEASE (for Medical Staff & Allied Health Staff Applicants) In connection with my application for affiliation (including contract for services) with Lawrence Memorial Hospital I hereby fully release and discharge you and Healthcare Employment Screening (HES), their respective affiliates, subsidiaries, directors, officers, employees, agents and attorneys thereof, and each of them, and any individual, organization, entity, agency, or other source providing information to above named employer and/or HES from all claims and damages arising out of or relating to any investigation of my background for employment purposes. I have been provided a copy of the summary of the rights of the consumer pursuant to Fair Credit Reporting Act (FCRA), and have also been provided a disclosure that an investigative consumer report will be sought pursuant to FCRA. I hereby authorize and give my consent to the above company for the procurement of consumer report(s). If hired (or contracted), this authorization will remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period. In connection with my application for employment (including contract for services) with you, I understand that an investigative consumer report and consumer reports which may contain public record information may be requested from HEALTHCARE EMPLOYMENT SCREENING, 4500 S. 129 th E. Ave. Suite 200, Tulsa, OK These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, any information relating to my character, general reputation, personal characteristics, mode of living, educational background, or any other information about me which may reflect upon my potential for employment gathered from any individual, organization, entity, agency, or other source which may have knowledge concerning any such items of information. I further understand that such reports may contain public record information concerning my driving record, workers compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records. You have the right to receive from _Lawrence Memorial Hospital upon your written request within a reasonable period of time, a complete and accurate disclosure of the nature and scope of the investigation requested. For purposes of gathering this information, I agree to supply the following information: Date of Birth Male Female First Full Middle Last Social Security #: / Applicant s Signature Date I/Medical Staff/Forms/Healthcare Employment Screening

8 Declaration of Ability to Practice for Medical Staff Applicants I, declare that to the best of my knowledge there is no (Print your Name) reason that I cannot carry out the obligations and prerogatives of Medical Staff Membership at Lawrence Memorial Hospital and perform the clinical privileges I have requested without exposing myself or others to significant health or safety risks. Signature Date Bottom Portion to be confirmed by your personal physician or for new applicants only, from the director of your training program or the Chief of Staff at a hospital at which you hold privileges. I concur with the declaration presented by the applicant of his/her ability to practice. Name & Address of Personal Physician/Director/Chief of Staff confirming declaration: (Name of Physician/Practice) (Address) (City/State/Zip) Signature Date Relationship to applicant: Personal physician Chief of Staff at Hospital at which applicant holds privileges Training program Director

9 Suit/Settlement Information Form Please supply the following information for each legal claim/suit/settlement or arbitration proceeding (including any dismissed or pending). A full disclosure of the following details is necessary prior to appointment/reappointment. Please type or print legibly. Practitioner Name Case number Case name vs. Date of occurrence Date/Place filed Your involved Professional Liability Insurance carrier Specifics in reference to the event Your status Primary Defendant Co-Defendant Other Your role in the event Status of the claim Total settlement amount Amount of damages paid attributable to your involvement in the case (if settled) Date of settlement Practitioner s Signature Date I/Medical Staff/Form/Credentialing Form/Suit/Settlement

10 LAWRENCE MEMORIAL HOSPITAL Safety Orientation Self Study Verification For Physicians, Residents, Contract Personnel, Temporary Help, Sitters, Forensic, Students, and Allied Health Personnel Welcome to Lawrence Memorial Hospital. It is our goal to provide health related services to our customers with a spirit of excellence and a personal touch of care. In this spirit we are providing a guide to the LMH Emergency Codes to foster a safe environment for you. Please take time to familiarize the Red Emergency Procedure Guide placed on each unit of the hospital. Also, notice where the exits are located as well as fire pull stations and fire extinguishers. If you have any questions, please ask staff who are in the vicinity. Once you have reviewed the Codes, please sign the bottom of this form and return it to the Medical Staff Office. We hope you have a good experience at LMH. Code Red Fire Code Blue or MET Team Medical Emergency Code Amber Infant/Child Abduction Code Silver Hostile Situation/Person with a Weapon Code Grey Combative Person Code Black Bomb Threat Code Orange Hazardous Material Decontamination Code Yellow Disaster Plan in Effect Code Clear The situation has been cleared Severe Weather Watch Watch Severe Weather Warning Warning I,, have reviewed the Lawrence Memorial Hospital Emergency Codes and feel I have a good understanding of the information. Date: Please return the signed form to the Medical Staff Office. I/Medical Staff/Forms/Credentialing Forms/Safety Orientation Self Study Verification (Revised 1/07)

11 LAWRENCE MEMORIAL HOSPITAL Alternate Designation Form Medical Staff Rule/Regulation 8.1 Emergency Coverage If the practitioner is to be available for patients having surgical, obstetrical or life-threatening medical or pediatric emergencies, he/she or his/her designated alternate should be available to respond to the Hospital by telephone within 10 minutes and be able to directly attend the patient s needs within an amount of time appropriate to the clinical situation It is the responsibility of the on-call physician to call his/her alternate physician if the alternate physician is providing emergency coverage Members of the Consulting Staff may be eligible for exemption from the alternate coverage requirements: i. If they specifically request an exemption at the time of initial appointment/reappointment; and ii. If their clinical privileges are limited to clinical consultation and/or non-invasive procedures When there are three or more Active Medical Staff members practicing an urgent subspecialty such as gastroenterology, infectious disease, otorhinolaryngology, pulmonary medicine, critical care, cardiology, neurology, interventional radiology, nephrology, orthopedic surgery, etc., either as a group of subspecialists or as a part of a group of general internists or surgeons, arrangements should be made so that those subspecialty services are continuously available. ALTERNATE DESIGNATION I DESIGNATE:, who has/have agreed to serve as my alternate(s) and who should be called to attend my patients in my absence. I understand that it is my responsibility to contact them to cover for me. Signed: Date: I/we agree to serve as the alternate(s) for coverage of the above-named s patients: Medical Staff & Allied Health Staff Conflict of Interest - Ethical & Legal Principles Signed: Signed: Signed:

12 Code of Conduct Acknowledgement Acknowledgment of Responsibility I have been asked by Lawrence Memorial Hospital to affirm my commitment to ethical and legal principles and conduct. I am also asked to reaffirm my understanding of my responsibilities in disclosing any potential conflict of interest that might in any way be construed as influencing or rewarding of a particular course of action. I do understand that Lawrence Memorial Hospital places great emphasis on upholding these values. By my signature below, I acknowledge that I made the commitment set forth below at the time of my affiliation and continue to reaffirm my obligation to it. To the best of my knowledge, Lawrence Memorial Hospital operates in a legal and ethical manner with all patients, Medical Staff, associates, volunteers, vendors, third-party payers and all others viewed as customers of our Hospital. I understand my responsibility as a member of the Medical or Allied Health Professional Staff in assuring the legal and ethical behavior of the Hospital and in reporting any potential deviation from its legal and ethical standards as defined in the organization Corporate Compliance Plan to the Corporate Compliance Officer or Chief Executive Officer. I agree to abide by the LMH Code of Conduct. I have no knowledge of any wrongdoing by this organization (LMH), or any of its employees, administrators, physicians, or other agents. I also understand that if I gain any knowledge of wrongdoing, I am to report this to the Corporate Compliance Officer or call the Compliance Concern Line. I further agree that should a possible conflict of interest arise during my affiliation/practice with LMH, I will immediately disclose that potential conflict to the President/Chief Executive Officer. I understand that violation of this agreement constitutes grounds for review and possible definitive action by my peers and/or the Board of Trustees. SIGNATURE of Medical Staff or Allied Health Professional Staff Member Date

13 LICENSED INDEPENDENT PRACTITIONERS SIGNATURE FORM Documentation Authentication Authentication can be verified through electronic signatures, written signatures or initials. My initials, written as such, shall be accepted as my signature on entries of the medical record. My written signature, written as such, shall be accepted as my signature on entries of the medical record. Physician Attestation Acknowledgement Federal regulations require that the physician attestation acknowledgement statement must be on file for each physician who admits MEDICARE and CHAMPUS patients to this facility. The statement must appear exactly as stated in the regulations. Please review the statement and sign. MEDICARE/CHAMPUS 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 Federal Laws. I acknowledge receipt of the above notice. Signed: Full signature Date: Printed name: [ ] cc: HIMS (Shirley Talbert) I/Medical Staff/Forms/Credentialing Forms/Physician Signature Form RC EP4

14 LMH requires Medical Staff Members, Allied Health Staff, employees and students to have a two step TB test upon initial hire/approval. This process must be completed prior to patient contact. RESULTS OF 1st TB SKIN TEST Name (print legibly): Date Name given: (print legibly): LEFT RIGHT FOREARM Date given: LEFT RIGHT FOREARM HAVE YOU PREVIOUSLY TESTED POSITIVE FOR TUBERCULOSIS? Yes No HAVE YOU PREVIOUSLY TESTED POSITIVE FOR TUBERCULOSIS? Yes No RESULTS at 48 hours RESULTS at (Results 48 hours are to be reported in mm, such as 0 mm, not as negative or positive.) (Results are to be reported in mm, such as 0 mm, not as negative or positive.) READ BY (Signature): DATE READ BY (Signature): DATE Please return this form to the L.M.H. Medical Staff Office Please return this form to the L.M.H. Medical Staff Office RESULTS OF 2nd TB SKIN TEST Name (print legibly): Date given: LEFT RIGHT FOREARM HAVE YOU PREVIOUSLY TESTED POSITIVE FOR TUBERCULOSIS? Yes No RESULTS at 48 hours (Results are to be reported in mm, such as 0 mm, not as negative or positive.) READ BY (Signature): DATE Please return this form to the L.M.H. Medical Staff Office