UNIVERSAL APPLICATION

UNIVERSAL APPLICATION This document was developed by the Medical Society of Milwaukee County and the coalition of integrated health care delivery systems and other physician organizations in Milwaukee County. 2004 INSTRUCTIONS: Applicant must fill out the application in its entirety and include all required documentation in accordance with the instructions given in the application cover letter. Failure to do so will result in the return of the application to the applicant and will delay processing. PERSONAL INFORMATION Last First Middle or Middle Initial Other s By Which You Have Been Known Professionally Degree Social Security Number Home Home City/State/Zip Home Phone Number (Include Area Code) City Wide Pager (Include Area Code) Answering Service (Include Area Code) Preferred E-Mail Address for professional correspondence Citizenship If not a US Citizen, specify status & Visa # Date of Birth Gender Birth City/State Male Female Birth Country Languages Spoken by Applicant Ethnic Origin (optional) Spouse s (optional) Emergency Contact Information (optional) Marital Status (optional) Phone: Married e-mail address Widowed OFFICES: List all practice sites, identify a primary, mailing and billing address. Office #1 Office Office Office Check all applicable boxes: Primary Office Secondary Office Mailing Address Billing Address Divorced Single Office Phone 1 (Include Area Code) Office Phone 2 (Include Area Code) Office Fax (Include Area Code) Languages Spoken at this Office Office Site Tax ID Office Contact/Office Manager Office #2 Office Office Office Check all applicable boxes: Primary Office Secondary Office Mailing Address Billing Address Office Phone 1 (Include Area Code) Office Phone 2 (Include Area Code) Fax (Include Area Code) Languages Spoken at this Office Office Site Tax ID Office Contact/Office Manager 10/01/01 DAV 1

Office #3 Office Office Office Check all applicable boxes: Primary Office Secondary Office Mailing Address Billing Address Office Phone 1 (Include Area Code) Office Phone 2 (Include Area Code) Office Fax (Include Area Code) Languages Spoken at this Office Office Site Tax ID Office Contact/Office Manager Type of Practice: Primary Care Specialist Accepting New Patients: Communications Available: TTY Teletypewriter Sign Language SPECIALTIES Specialty Primary Secondary Board Certified ( or ) of Board Year Certified Last Re- Certified Expiration Date ID NUMBERS State License: List all current and past state licenses. State of Licensure Number Type Expiration Date DEA Number UPIN Number Other ID Numbers Type of Number Number Expiration Date (where applicable) ECFMG Number (if applicable) Please also include a copy Medicare Provider Number Medicaid Provider Number 10/01/01 DAV 2

HOSPITAL & ASC AFFILIATIONS: NEW APPLICATIONS: List all hospitals, ambulatory surgery centers and medical offices where you have ever had an affiliation or where you have an application in process. Indicate affiliation status (Active, Courtesy, Provisional, Temporary, etc.) Begin with current affiliations and then list past affiliations. Enter additional affiliations on a separate sheet of paper and attach to the application. Do not include Residency or Internship information in this area. REAPPOINTMENT: List hospitals where you have had an affiliation at any time in the past two years. Include current affiliation status. 10/01/01 DAV 3

EDUCATION AND TRAINING Medical Education or Professional School of Institution Start & Finish Dates (Month & Year) Phone Number (Include Area Code) Fax Number (Include Area Code) E-Mail Address Degree Obtained of Institution Start & Finish Dates (Month & Year) Phone Number (Include Area Code) Fax Number (Include Area Code) E-Mail Address Degree Obtained Internship Residency 10/01/01 DAV 4

Fellowship ADDITIONAL FORMAL TRAINING, such as Preceptorships, etc.: CLINICAL TEACHING APPOINTMENTS: List current and previous clinical teaching appointments. of Institution Rank Start & Finish Dates (Month & Year) of Institution Faculty Rank Start & Finish Dates (Month & Year) 10/01/01 DAV 5

MILITARY EXPERIENCE: List all military experience that has occurred since completion of medical school. of Institution Rank Start & Finish Dates (Month & Year) of Institution Faculty Rank Start & Finish Dates (Month & Year) PRACTICE AFFILIATION: List all practice history (past & present) that has occurred since completion of medical or professional school. Explain all gaps of 30 days or more in next section. of Institution Job Title Start & Finish Dates (Month & Year) of Institution Job Title Start & Finish Dates (Month & Year) of Institution Job Title Start & Finish Dates (Month & Year) of Institution Job Title Start & Finish Dates (Month & Year) of Institution Job Title Start & Finish Dates (Month & Year) of Institution Job Title Start & Finish Dates (Month & Year) 10/01/01 DAV 6

EXPLANATION OF WORK HISTORY GAP: Any time periods or gaps since graduation from medical school of greater than 30 days, which are not explained in the application thus far, must be addressed here. If the application is found to have any unexplained time periods or gaps since medical school of greater than 30 days, the application will not be processed and will be returned to the applicant as incomplete. Please explain any such gaps in the space provided below From Date To Date Explanation of Work History Gap PROFESSIONAL LIABILITY INSURANCE Current Liability Carrier of Company Complete Address Start Date (Month & Year) Policy Number Phone Number (Include Area Code) Fax Number (Include Area Code) E-Mail Address Coverage Amounts Previous Liability Carriers (List all carriers for past 10 years) of Company Complete Address Start & Finish Dates (Month & Year) Policy Number Phone Number (Include Area Code) Fax Number (Include Area Code) E-Mail Address Coverage Amounts of Company Complete Address Start & Finish Dates (Month & Year) Policy Number Phone Number (Include Area Code) Fax Number (Include Area Code) E-Mail Address Coverage Amounts 10/01/01 DAV 7

Professional Liability Action Explanation Form This form must be completed if you answered yes to question #1 on the Disclosure Questions of the Practitioner Application Form. Please complete this form for each pending or settled professional liability action or any payment made on behalf of applicant. All questions must be answered completely. If additional sheets are required, please photocopy this page prior to completing. Please provide us with a separate sheet for each malpractice action. In order to maintain HIPAA compliance please remove all patient identifiers (i.e. name, DOB) from submitted documents. Please Print Date of Alleged Incident Docket Number Date Suit Filed City/State of Incident Your Relationship to Patient (Attending Practitioner, Surgeon, Assistant Surgeon, Consultant, etc.) Additional d Defendant(s) Liability Carrier When Incident Occurred Allegation Claim Status OPEN If open, amount being sought CLOSED If closed, indicate method of closing Dismissal Settlement Judgment Amount of settlement or judgment Summarize the circumstances giving rise to the action. If the action involves patient care, describe a narrative that provides your care and treatment of the patient. If additional space is necessary, attach adequate clinical detail to allow proper evaluation by a committee of physicians. Include 1) condition and diagnosis at time of incident, 2) dates and description of treatment rendered and 3) condition of patient subsequent to treatment. In order to maintain HIPAA compliance please remove all patient identifiers (i.e. name, DOB) from submitted documents. Please print. SUMMARY 10/01/01 DAV 8

Verification of Professional Liability Insurance Please copy and complete the following form for each credentialing organization to which you are applying. Naming each credentialing organization as Certificate Holder on the malpractice policy will facilitate automatic notification of renewal to that organization by the malpractice carrier and eliminate the need for the practitioner to provide copies to each organization at every renewal. I, the undersigned, authorize my professional liability insurance carrier, of Insurance Carrier of Insurance Carrier City State Zip Code Policy Number to send verification of my professional liability coverage, to include dates of coverage, amounts of coverage and any limitations in coverage to who will hereinafter be a Certificate Holder and is to be notified of the amount of my coverage and any future changes to my insurance status. Requested by: Printed Signature: Date: Signature: 10/01/01 DAV 9

DISCLOSURE QUESTIONS - If you answer YES to questions numbered 2 through 18, please provide details on a separate page. Include a copy of any order or settlement where applicable. 1. Have there ever been, or are there currently, any professional or work-related claims, settlements or judgments against you, your employer, or other third party, even if not resulting in monetary damages, or have you received any notice of Intent to File? IF YOU ANSWER YES, PLEASE PROVIDE DETAILED INFORMATION ON THE ENCLOSED PROFESSIONAL LIABILITY ACTION EXPLANATION FORM. 2. Have you ever had any professional liability insurance coverage voluntarily or involuntarily canceled, declined or modified (i.e., reduced limits, restricted coverage), or has any renewal ever been refused, or have you voluntarily given up coverage? 3. Have you ever been denied, or have you voluntarily or involuntarily given up, membership, or renewal of membership, or been subject to any disciplinary action in any hospital, IPA, HMO, PHO, PPO, managed care organization or professional society, or is any such action pending? 4. Have your clinical privileges or employment at any hospital or healthcare institution been voluntarily or involuntarily limited, suspended, revoked, not renewed, or subject to probationary or other disciplinary conditions, or have proceedings toward any of those ends been instituted or recommended by a hospital administration, medical staff or committee or governing board? 5. Has your request for any specific clinical privileges been voluntarily or involuntarily denied or granted with stated limitations (aside from ordinary and initial requirements of proctorship) or has such a denial or limitation been recommended by a medical staff or committee or governing board? 6. Have you ever had any previous or pending challenges to, or voluntarily or involuntarily relinquished any medical staff membership, clinical privilege(s), professional license(s), or narcotics registration as the result of any investigation or disciplinary action? 7. Have you ever been disciplined by any State Board of Medical Examiners, or by any Professional Conduct Board, or have you ever been reprimanded, or fined by any state or federal agency that disciplines physicians or allied health professionals? 8. Have you ever been reprimanded, censured, excluded, suspended or disqualified by Medicare, Medicaid, CLIA or any other health plan for which you provide services? 9. Have you ever received notice of a proposed or actual exclusion from any health care program funded in whole or part by the federal government or any state health care program, including Medicare or Medicaid? 10. Has your Drug Enforcement Agency or other controlled substances authorization ever been voluntarily or involuntarily denied, revoked, suspended, reduced or not renewed, or have proceedings toward any of those ends been instituted? 11. Has your specialty board certification or eligibility ever been voluntarily or involuntarily denied, revoked, relinquished, not renewed, suspended, reduced, or have any proceedings toward any of those ends been instituted? 12. Has your authorization to practice in any jurisdiction (state or county) ever been voluntarily or involuntarily revoked, suspended, or subject to probation or any conditions or limitations? 13. Have you ever been convicted of, or pleaded guilty or no contest to, a felony, serious or gross misdemeanor, or any crime or municipal violation, involving dishonesty, assault or sexual misconduct or abuse, or abuse of controlled substances or alcohol, or are charges pending against you for any such crimes by information, indictment or otherwise? 14. To your knowledge, has any information pertaining to you ever been reported to the National Practitioner Data Bank (NPDB)? 15. Will practicing to the fullest extent of your licensure, qualifications, and privileges, with or without reasonable accommodation, in any way pose a risk of harm to your patients? 16. In the past five years, up to, and including the present, have you had a history of chemical dependency or substance abuse that might affect your ability to competently and safely perform the essential functions of a practitioner in your area of practice? 17. Have you ever been court-martialed, investigated, sanctioned, reprimanded or cautioned by a hospital or other healthcare facility of any military agency, been involuntarily terminated or forced to resign, or have you resigned voluntarily while under investigation or threat of sanction from a hospital or healthcare facility of any military agency? 18. If you perform clinical research, have you ever had any clinical research study terminated involuntarily, been asked to terminate a clinical research study before it was completed or had any other discipline or sanctions with respect to your clinical research? (Continue to page 11) 10/01/01 DAV 10

19. Is your professional liability insurance current? (Please read this question carefully) in residency/ fellowship 20. Do your professional liability insurance amounts meet state minimum requirements? (Please read this question carefully) in residency/ fellowship I understand and agree that the burden of producing adequate information in a timely manner and for resolving doubts is my responsibility. I understand and agree that the application will not be processed until the application is deemed complete by the healthcare organization. It is my responsibility to provide a complete application. I certify that the information in this document and any attached documents is true, correct, and complete. I understand and agree that any misrepresentation, misstatement, or omission from this application, if discovered after staff membership/privileges or network participation has been awarded to me, may lead to suspension or termination of that membership/privileges and/or participation. Practitioner Signature (Stamped Signatures are Unacceptable) Date 10/01/01 DAV 11

DEPARTMENT OF HEALTH AND FAMILY SERVICES STATE OF WISCONSIN HFS-64 (Rev. 09/00) BACKGROUND INFORMATION DISCLOSURE INSTRUCTIONS The Background Information Disclosure form (HFS64) gathers information as required by the Wisconsin Caregiver Background Check Law to help employers and governmental regulatory agencies make employment, contract, residency, and regulatory decisions. Complete and return the entire form and attach explanations as specified by employer or governmental regulatory agency. CAREGIVER BACKGROUND CHECK LAW In accordance with the provisions of sections 48.685 and 50.065 of the Wisconsin Statutes, for persons who have been convicted of certain acts, crimes or offenses: 1. The Department of Health and Family Services (DHFS) may not license, certify or register the person or entity (te: Employers and Care Providers are referred to as entities ); 2. A county agency may not certify a day care or license a foster or treatment foster home; 3. A child placing agency may not license a foster or treatment foster home or contract with an adoptive parent applicant for a child adoption; 4. A school board may not contract with a licensed day care provider; and 5. An entity may not employ, contract with, or permit persons to reside at the entity. A list of barred crimes and offenses requiring rehabilitation review is available from the regulatory agencies or through the Internet at http://www.dhfs.state.wi.us/ at the licensing link and then under the Caregiver Program link. THE CAREGIVER LAW COVERS THE FOLLOWING EMPLOYERS/CARE PROVIDERS (REFERRED TO AS ENTITIES ) Programs Regulated Under Chapter 48 of Wisconsin Statute Programs Regulated Under Chapters 50, 51, and 146 of Wisconsin Statute Others Treatment Foster Care, Family Day Care Centers, Group Day Care Centers, Residential Care Centers for Children and Youth, Child Placing Agencies, Day Camps for Children, Family Foster Homes for Children, Group Homes for Children, Shelter Care Facilities for Children, and Certified Family Day Care. Emergency Mental Health Service Programs, Mental Health Day Treatment Services for Children, Community Mental Health, Developmental Disabilities, AODA Services, Community Support Programs, Community Based Residential Facilities, 3-4 Bed Adult Family Homes, Residential Care Apartment Complexes, Ambulance Service Providers, Hospitals, Rural Medical Centers, Hospices, Nursing Homes, Facilities for the Developmentally Disabled, and Home Health Agencies including those that provide personal care services. Day Care Providers contracted through Local School Boards THE CAREGIVER LAW COVERS THE FOLLOWING PERSONS Anyone employed by or contracting with a covered entity who has access to the clients served, except if the access is infrequent or sporadic and service is not directly related to care of the client. Anyone who is a Day Care Provider who contracts with a School Board under Wisconsin Statute 120.13 (14). Anyone who lives on the premises of a covered entity and is 10 years old or over, but is not a client ( non-client resident ). Anyone who is licensed by DHFS. Anyone who has a foster home licensed by DHFS. Anyone certified by DHFS. Anyone who is a Day Care Provider certified by a county department. Anyone registered by DHFS. Anyone who is a board member or corporate officer who has access to the clients served. FAIR EMPLOYMENT ACT Wisconsin s Fair Employment Law, ss. 111.31-111.395, Wisconsin Statutes, prohibits discrimination because of a criminal record or pending charge; however, it is not discrimination to decline to hire or license a person based on the person s arrest or conviction record if the arrest or conviction is substantially related to the circumstances of the particular job or licensed activity. PERSONALLY IDENTIFIABLE INFORMATION: This information is used to obtain relevant data as required by the provisions set forth by the Wisconsin Caregiver Background Check Law. Providing your social security number is voluntary, however your social security number is one of the unique identifiers used to prevent incorrect matches. For example, the Department of Justice uses social security numbers, names, gender, race, and date of birth to prevent incorrect matches of persons with criminal convictions. The Department of Health and Family Services Caregiver Registry uses social security numbers as one identifier to prevent incorrect matches of persons with findings of abuse or neglect of a client or misappropriation of a client s property. 10/01/01 DAV 12

BACKGROUND INFORMATION DISCLOSURE Completion of this form is required under the provisions of sections 48.685 and 50.065 of the Wisconsin Statutes. Failure to comply may result in a denial or revocation of your license, certification or registration; or denial or termination of your employment or contract. Refer to the attached instructions (HFS-64 A) for additional information. Providing your social security number is voluntary, however your social security number is one of the unique identifiers used to prevent incorrect matches. Please print your answers. Check the box that applies to you. Employee / Contractor (Including new applicant) Household member/lives on premises - but not a client Applicant for a license or certification or registration (including Other specify: continuation or renewal) NOTE: If you are an owner, operator, board member, or non-client resident of a Bureau of Quality Assurance (BQA) regulated facility (1) print only your first, middle and last name; (2) complete Sections A and B; (3) sign the form; (4) complete the Appendix, HFS-69, in its entirety and (5) submit this form and the Appendix to the address noted in the Appendix instructions. - First and Middle - Last Position Title (Complete only if you are a prospective employee or contractor, or a current employee or contractor.) Any other names by which you have been known (including maiden name) Birthday Gender (M/F) Race Address Social Security Number(s) Business and Address of Employer or Care Provider (Entity) Section A - ACTS, CRIMES AND OFFENSES THAT MAY ACT AS A BAR OR RESTRICTION YES NO 1. Do you have criminal charges pending against you or were you ever convicted of any crime anywhere, including in federal, state, local, military, and tribal courts? If, list each crime, when it occurred or the date of the conviction, and the city and state where the court is located. You may be asked to supply additional information including a certified copy of the judgment of conviction, a copy of the criminal complaint, or any other relevant court or police documents. 2. Were you ever found to be (adjudicated) delinquent by a court of law on or after your 10 th birthday for a crime or offense? (NOTE: A response to this question is only required for group and family day care centers for children and day camps for children.) If, list each crime, when and where it happened, and the location of the court (city and state). You may be asked to supply additional information including a certified copy of the delinquency petition, the delinquency adjudication, or any other relevant court or police documents. 3. Has any government or regulatory agency (other than the police) ever found that you committed child abuse or neglect? A response is required if the box below is checked: (Only employers and regulatory agencies entitled to obtain this information per sec. 48.981(7) are authorized to, and should, check this box.) If, attach an explanation, including when and where it happened. 4. Has any government or regulatory agency (other than the police) ever found that you abused or neglected any person or client? If, attach an explanation, including when and where it happened. 5. Has any government or regulatory agency (other than the police) ever found that you misappropriated (improperly took or used) the property of a person or client? If, attach an explanation, including when and where it happened. 6. Has any government or regulatory agency (other than the police) ever found that you abused an elderly person? If, attach an explanation, including when and where it happened. 7. Do you have a government issued credential that is not current or is limited so as to restrict you from providing care to clients? If, attach an explanation, including credential name, limitations or restrictions, and time period. 10/01/01 DAV 13

Section B OTHER REQUIRED INFORMATION YES NO 1. Has any government or regulatory agency ever limited, denied or revoked your license, certification or registration to provide care, treatment or educational services? If, attach an explanation, including when and where it happened. 2. Has any government or regulatory agency ever denied you permission or restricted your ability to live on the premises of a care providing facility? If, attach an explanation, including when and where it happened and the reason. 3. Have you been discharged from a branch of the US Armed Forces, including any reserve component? If, attach a copy of your discharge papers (DD214) if you were discharged within the past 3 years. You may be asked to provide a copy of your DD214 if your discharge occurred more than 3 years ago. 4. Have you resided outside of Wisconsin in the last 3 years? If, list each State, County within the State and the dates in which you lived there. 5. Have you had a caregiver background check done within the last 4 years? If, list the date of each check, and the name, address and phone number of the person, facility or government agency that conducted each check. 6. Have you ever requested a rehabilitation review with the Wisconsin Department of Health and Family Services, a county department, a private child placing agency, school board, or DHFS designated tribe? If, list the review date and the review result. You may be asked to provide a copy of the review decision. A NO answer to all questions does not guarantee employment, residency, a contract, or regulatory approval. I understand, under penalty of law, that the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in a forfeiture of up to $1000.00 and other sanctions as provided in HFS 12.20 (1) (c), Wis. Adm. Code. YOUR SIGNATURE Date Signed This document was developed by the Medical Society of Milwaukee County and the coalition of integrated health care delivery systems and other physician organizations in Milwaukee County. 2003 10/01/01 DAV 14