APPLICATION FOR CLINICAL PRIVILEGES/MEDICAL STAFF APPOINTMENT PRIVACY ACT STATEMENT Authority 10 U.S.C. Chapter 55 and Section 8067 and 8013 and EO 9397 Principal Purpose To evaluate each practitioner's formal education, training, clinical experience, and evidence of physical moral, and ethical capacities and to assist the Credentials function in making recommendations with regard to the practitioner's competence to treat certain conditions and perform certain medical procedures. Routine Use Information may be released to government boards or agencies or professional societies or organizations if needed to license or monitor professional standards of health care practitioners. It may also be released to civilian medical institutions or organizations where the practitioner is applying for staff privileges during or after separation from the service. Disclosure Disclosure is voluntary. However, failure to provide information may result in the limitation or termination of clinical privileges. SECTION I - IDENTIFICATION NAME (LAST, FIRST MI) RANK/GRADE SSN CITIZENSHIP DOB(YYYYMMDD) GENDER SVC BRANCH CORPS AFSC/AOC/DESIG DUTY SECTION DUTY PHONE MEDICAL/DENTAL FACILITY COMPLETE OFFICE ADDRESS PHONE NO. ALIAS NAME(LAST, FIRST MIDDLE) COMPLETE CURRENT/HOME/LOCAL ADDRESS PHONE NO. REPORT PCS/PRD
SECTION II - PROFESSIONAL EDUCATION SCHOOL ADDRESS S ATTENDED FROM TO DEGREE FOREIGN TRAINED FIFTH PATHWAY COMPLETED SCHOOL ADDRESS S ATTENDED FROM TO DEGREE FOREIGN TRAINED FIFTH PATHWAY COMPLETED SCHOOL ADDRESS S ATTENDED FROM TO DEGREE FOREIGN TRAINED FIFTH PATHWAY COMPLETED SCHOOL ADDRESS S ATTENDED FROM TO DEGREE FOREIGN TRAINED FIFTH PATHWAY COMPLETED SECTION III - POSTGRADUATE TRAINING (Most Recent First) INSTITUTION PROGRAM TYPE INT/RES/FEL FIELD S ATTENDED FROM TO COMPLETED INSTITUTION PROGRAM TYPE INT/RES/FEL FIELD S ATTENDED FROM TO COMPLETED INSTITUTION PROGRAM TYPE INT/RES/FEL FIELD S ATTENDED FROM TO COMPLETED SECTION IV - SPECIALTY CERTFICATE SPECIALITY/SUBSPECIALTY LEVEL CERTIFYING BOARD NUMBER CERTFICATE SPECIALITY/SUBSPECIALTY LEVEL CERTIFYING BOARD NUMBER CERTFICATE SPECIALITY/SUBSPECIALTY LEVEL CERTIFYING BOARD NUMBER
SECTION V - LICENSE/CERTIFICATION/REGISTRATION TYPE NUMBER STATE FIELD License ADM WAIVER TYPE NUMBER STATE FIELD License ADM WAIVER TYPE NUMBER STATE FIELD License ADM WAIVER TYPE NUMBER STATE FIELD License ADM WAIVER TYPE NUMBER STATE FIELD License ADM WAIVER DOCUMENT TYPE NUMBER STATE SPECIALTY Certification DOCUMENT TYPE NUMBER STATE SPECIALTY Certification DOCUMENT TYPE NUMBER STATE SPECIALTY Registration
SECTION V - LICENSE/CERTIFICATION/REGISTRATION (Continued) DOCUMENT TYPE NUMBER STATE SPECIALTY Registration UNLICENSED REASON LICENSURE STATE SECTION VI - DRUG ENFORCEMENT ADMINISTRATION/STATE CONTROLLED SUBSTANCE REGISTRATION FEDERAL DEA TYPE NUMBER VERIFIED FEDERAL DEA TYPE NUMBER VERIFIED CDS TYPE NUMBER STATE VERIFIED CDS TYPE NUMBER STATE VERIFIED SECTION VII - MILITARY OR CIVILIAN ASSIGNMENTS/ACADEMIC APPOINTMENTS/PROFESSIONAL AFFILIATIONS A. MILITARY OR CIVILIAN ASSIGNMENT (Most recent 10 years to include Gaps. Gaps must be explained.) MTF OR INSTITUTION ADDRESS SPECIALTY S ASSIGNED APPOINTMENT PRIVILEGES OFF DUTY FROM TO TYPE HELD EMPLOYMENT B. ACADEMIC AFFILIATIONS S ASSIGNED INSTITUTION ADDRESS POSITION FROM TO
C. ORGANIZATIONAL MEMBERSHIPS S ASSIGNED ORGANIZATION ADDRESS OFFICE FROM TO SECTION VIII - CONTINUING EDUCATION CREDITS A. ACADEMIC START COMPLETION INSTITUTION COURSE TITLE/SUBJECT CONTINUING CREDIT CREDIT COURSE NO. / EDUCATION TYPE HOURS CATEGORY SPONSOR B. CONTINGENCY TRAINING - TRAINING INSTRUCTOR SECTION IX - REFERENCES NAME TITLE/POSITION PHONE NUMBER FAX NUMBER ADDRESS EMAIL NAME TITLE/POSITION PHONE NUMBER FAX NUMBER ADDRESS EMAIL NAME TITLE/POSITION PHONE NUMBER FAX NUMBER ADDRESS EMAIL NAME TITLE/POSITION PHONE NUMBER FAX NUMBER ADDRESS EMAIL NAME TITLE/POSITION PHONE NUMBER FAX NUMBER ADDRESS EMAIL
SECTION X - PRACTICE HISTORY YES NO 1. On a voluntary or involuntary basis, has/have any staff appointment(s) ever been, or is/are in the process of being denied, terminated, discharged, revoked, suspended, reduced, limited, restricted, not renewed, withdrawn, or relinquished to avoid disciplinary or adverse privileging action? 2. On either a voluntary or involuntary basis, have your clinical privileges ever been, or are they in the process of being denied, revoked, suspended, reduced, limited, restricted, not renewed, withdrawn, or relinquished? 3. Have you ever been notified that the quality of the care you provided is being reviewed for an administrative claim for Damage, Injury, or Death, or a civil tort lawsuit filed concerning the healthcare provided to a patient? If YES, then in the comments section identify each claim/suit. If you are not sure whether a claim/suit has been filed, contact your local Risk Manager or attorney for assistance. 4. Has an administrative claim or civil tort lawsuit concerning the healthcare you provided to a patient ever been settled on your behalf? If YES, then in the comments section identify each claim/suit that was settled. If you are not sure whether a claim/suit has been settled, contact your local Risk Manager or attorney for assistance. 5. Have you ever been convicted of, pled guilty to, or pled nolo contendere to a crime? If YES, then please identify it in the comments section, even if you received alternative sentencing such as probation or deferred adjudication. 6. Have you ever been charged, in either a civilian court or under the Uniform Code of Military Justice, with: assault; battery; a violent crime; a sexual offense; a drug or alcohol related offense; abuse or neglect; or any offense involving a child? If YES, then please identify it in the comments section. 7. Do you currently have charges pending for any violation of law? If YES, please provide a full explanation of the circumstances. 8. Have you ever resigned or retired from a clinical position after being notified: you would be disciplined or discharged; that you would be the subject of an investigation; or after questions about your clinical competence were raised and not resolved? 9. Has your license/certification/registration to practice, in your profession, ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation, or have you ever been subject to a consent order, probation, or any condition or limitation by any state? 10. Have you ever received a reprimand or been fined by any state that issues your professional license/certification/registration? 11. Is there currently pending or has your Federal DEA and/or DPS Controlled Substances Certificate or authorization ever been denied, suspended, revoked, or are any challenges or investigations pending? COMMENTS
SECTION X - PRACTICE HISTORY YES NO (CONTINUED) 12. Has your participation in Medicare/Medicaid, or any other federal or state governmental healthcare program ever been, or is in the process of being either on a voluntary or involuntary basis denied, revoked, suspended, reduced, limited, restricted, withdrawn, or relinquished while under investigation? 13. Has your participation in the Medicare/Medicaid or any other federal or state government program been investigated or subject of a conviction for making or using false, fictitious, or fraudulent statements, representations, writings or documents, regarding a material fact in connection with the delivery of, or payment for healthcare benefits, item or services that would be in violation of the Criminal False Claims Act? COMMENTS 14. Have you ever been investigated for alleged violation of the federal Anti- Kickback Statute concerning an offer, payment, solicitation or receipt of money, property or remuneration to induce or reward the referral of patients or healthcare services payable by a government health care program? 15. Have you ever been investigated for violations involving the Physician Self-Referral law, commonly known as Stark law, regarding referrals for health services payable by Medicare to an entity with which you (or an immediate family member) had a financial relationship (ownership, investment, or compensation)? 16. Is there currently pending or has there been on a voluntary or involuntary basis: a denial, revocation, suspension or non-renewal of your ECFMG Certification or Foreign Graduate Certification? 17. Is there currently pending or has there been on a voluntary or involuntary basis a denial, revocation, suspension, reduction, limitation, restriction, nonrenewal, or relinquishment either while under investigation or in lieu of disciplinary action, of your participation or membership in a Healthcare Organization (PPO, MCO, etc.) or Professional Society? 18. Has your faculty membership in any professional school been removed or subject to disciplinary action? 19. Are you currently in default on repayments of scholarship obligations or loans in connection with health professions education made or secured in whole or in part by the government? 20. Have you ever been denied professional insurance, or has your policy ever been cancelled?
SECTION XI - HEALTH YES NO 1. Do you currently have a physical or mental impairment which might interfere with your ability to perform the procedures and essential functions of the position for which you have applied or requested clinical privileges, with or without accommodation, according to accepted standards of professional performance and without posing a direct threat to other staff or patients? 2. Are you currently taking any medications that may interfere with your ability to perform the procedures and essential functions of the position for which you have applied or requested clinical privileges, with or without accommodation, according to accepted standards of professional performance and without posing a direct threat to other staff or patients? 3. Do you have any reason to believe that you could pose a risk to the safety or well-being of your patients? 4. Are you currently engaged in the illegal use of drugs? "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, and includes unlawful use of prescription controlled substances. 5. Are you currently under treatment for an alcohol or drug related condition? COMMENTS
SECTION XII - CLINICAL PRIVILEGES REQUESTED ORGANIZATION UNIT MILTARY/CIVILIAN ADMITTING Age Groups: NeoNates (Birth-28 Days) Adolescents (13-17 yrs) Geriatrics(>65 yrs) Infants (1-24 mos) Young Adults(18-23 yrs) Children (2-12 yrs) Adults (24-65 yrs) INSTRUCTIONS APPLICANT: -------------------------- In the Provider column, enter Code 1, 2, or 4 for every privilege listed. This is to reflect you current capability to perform the privilege based on your education, training, current competency and ability to perform and should not consider any known facility limitations. (Make all entries in ink.) LEVEL 1 REVIEWER: ------------- Using the facility privileges list, enter Code 1, 2, 3, or 4 in each LEVEL 1 block for each requested privilege. (Make all entries in ink.) CODES: -------------------------------- 1 - Fully competent within defined cope of practice. (Clinical oversight of some allied health providers is required as defined in Service Instructions.) 2 - Supervision required. (Unlicensed/uncertified or lacks current relevant clinical experience. (***ONLY USED FOR ARMY and AIR FORCE***) 3 - Not approved due to lack of facility support. (Reference facility master privileges list.) 4 - Not requested by application/not approved due to lack of expertise or proficiency, or due to physical disability or limitation. PRIVILEGE CATEGORY: Audiology Family Medicine - Version 1.0 - Scope Privilege(s) Provider Level 1 (C) The scope of privileges in Audiology includes the evaluation, diagnosis, treatment and consultation for patients of all ages with dysfunction in hearing, auditory function, vestibular balance, and related disorders. Audiologists manage the hearing conservation program, perform worksite assessment of noise exposure, and noise measurement and analysis. Diagnosis and Management (D&M): Privilege(s) Provider Level 1 (C) Tinnitus assessment, rehabilitation and management (C) Vestibular and balance assessment and management (C) Rehabilitation counseling and training (C) Hearing protective device fabrication and fitting (C) Hearing protection fit check assessment (C) Hearing aid candidacy assessment, selection, fitting, and counseling (C) Fitness for duty examinations Procedures Privilege(s) Provider Level 1 (C) Pure tone and speech audiometry (C) Acoustic emittance and auditory reflex evaluation (C) Otoacoustic emissions testing (C) Speech in Noise testing (filtered speech) (C) Auditory evoked potentials (C) Earmold fabrication, fitting and modification (C) Electroacoustic measurement of hearing aids (C) Verification measurement (i.e. Real Ear, functional assessments) D & M Advanced Privileges (Requires Additional Training) Privilege(s) Provider Level 1 (C) Cerumen management Facility Facility Facility Facility Comments Comments Comments Comments
SECTION XIII - STAFF APPOINTMENT/PRIVILEGES> TYPE OF APPOINTMENT TYPE OF PRIVILEGES SECTION XIV - Comments> SECTION XV - Malpractice Insurance MALPRACTICE INSURANCE ADDRESS POLICY NUMBER AFFILIATION NAME SECTION XVI - STATEMENT OF APPLICANT/SIGNATURE BLOCK I certify that (check appropriate box for each paragraph): YES NO 1) All information submitted by me in this application is true to the best of my knowledge and belief. I understand any false or incomplete information knowingly provided on or with this application may be grounds for not employing or accessing me, or for dismissing or releasing me if I am already employed or serving. I understand that knowingly providing false or incomplete information is punishable by fine or imprisonment under U.S. Code Title 18, Section 1001. 2) I possess the credentials and current clinical competence to justify the granting of staff appointment with clinical privileges as requested. 3) I have been provided a copy or access to the professional staff policies, procedures, and bylaws of the facility and an opportunity to read those documents. I agree to comply with the professional staff policies, procedures, and bylaws of the facility. 4) I have been provided access to and agree to comply with the applicable credentials and privileging directives. 5) I have no current mental or physical impairment that could limit my clinical abilities. 6) I will notify the privileging authority and my commanding officer, if different from privileging authority, of any change in my mental or physical condition that could limit my clinical ability or performance. 7) I pledge to provide continuous care for my patients. 8) To my knowledge, I am not currently under investigation involving substandard clinical practice, malpractice, or personal misconduct. 9) For the purpose of evaluating my professional competence, character, and ethical conduct, I authorize the appropriate staff or the agents of, to contact and consult with: Administrators and members of the professional staff of any other treatment facility, institution, or practice with which I have been associated, current or past malpractice carriers and my professional colleagues. I release from liability all individuals or organizations who respond honestly and in good faith to inquiries authorized in paragraphs above. Applicant Signature
SECTION XVII - REVIEWER INFORMATION BLOCK Confirmation of applicant's statement attesting there are no physical or mental impairments which could limit the clinical practice to perform privileges requested. SECTION XVIII - PRIVILEGING AUTHORITY SIGNATURE BLOCK Action Comments Privileging Authority Signature APPENDED PRIVILEGES/APPOINTMENT PRIVILEGING/APPOINTMENT TYPES OR S WERE APPENDED Name Reason