Application for Clinical Privileges Initial Application 3241 S. Michigan Ave. Chicago, IL 60616 Phone: 312-949-7211 Fax: 312-949-7389
SECTION ONE PERSONAL INFORMATION and BACKGROUND NAME DATE OF APPLICATION (Last) (First) (MI) RESIDENCE ADDRESS (Street) (City) (State) (Zip Code) SSN # Home Telephone ( ) Email : Cell Phone ( ) Date of Birth Citizenship If not a US citizen, Please indicate status of your visa: OFFICE ADDRESSES: 1. Illinois Eye Institute 3241 South Michigan Ave. Chicago, IL 60616 TELEPHONE (_312_) 949-7211 2. TELEPHONE ( ) I. EDUCATION UNDERGRADUATE COLLEGE OR UNIVERSITY DEGREE & MONTH/YEAR EARNED EDUCATION: PROFESSIONAL OPTOMETRY/ MEDICAL SCHOOL, OTHER DEGREE & MONTH/YEAR EARNED EDUCATION: Application for Clinical Privileges/ Illinois Eye Institute 2
POST-GRADUATE INSTITUTION DEGREE(S) & YEAR EARNED EDUCATION: RESIDENCIES/ LOCATION DIRECTOR DATES FELLOWSHIPS: (List all started) II. AFFILIATIONS: NAMES/ LOCATIONS OF, HOSPITALS, INSTITUTIONS,OR AGENCIES CAPACITY DATES (Please list current/past affiliations for the last five years. Use separate sheet if necessary.) III. REFERENCES: Please provide current, complete information for three references (at least two optometrists) since any/all of these references will be contacted. References will be evaluated according to the extent of their direct clinical observation of your work and other knowledge of you. References should not include relatives or current partners. NAME PHONE RELATIONSHIP 1. ( ) Address: 2. ( ) Address: 3 ( ) Address: Application for Clinical Privileges/ Illinois Eye Institute 3
IV. PROFESSIONAL LICENSING PROFESSION STATE LICENSE # EFFECTIVE DATES 1. 2. 3. DEA REGISTRATION # State Controlled Substance # V. CURRICULUM VITAE Note: Your CV MUST include MONTHS on all dates. On separate sheet(s) furnish updated C. V. including scientific papers, written and/or presented, scientific meetings attended, and clinical education courses given. VI. MEMBERSHIP IN PROFESSIONAL SOCIETIES Please list current membership in local (county), state, or national professional societies (Give name) NAME DATES VII. PROFESSIONAL CLINICAL EXPERIENCE SERVICE/SPECIALTY DATES ILLINOIS EYE INSTITUTE PRIVATE PRACTICE Application for Clinical Privileges/ Illinois Eye Institute 4
OTHER EXPERIENCE MILITARY SERVICE VIII. CERTIFICATION EFFECTIVE DATES FELLOW, COVD FELLOW, AAO DIPLOMATE, AAO (list Section) DIPLOMATE APPLICATIONS (list Section and status) THERAPEUTIC AGENTS CERTIFICATION (list course taken, if applicable) CURRENT CPR CERTIFICATION (list level of certification) IX. INSURANCE In addition to professional liability insurance provided by ICO/IEI, list your other carrier(s) for professional liability insurance, if any. Policy # Carrier Expiration Date AGENT ADDRESS X. HEALTH STATUS Are you able to safely and competently perform the clinical privileges requested with or without reasonable accommodation? Yes No Application for Clinical Privileges/ Illinois Eye Institute 5
XI. ADDITIONAL INFORMATION If your answer to any of the following questions is "yes", please give details on separate sheet. 1. Has your license to practice your profession (optometry, medicine, etc.) in any jurisdiction ever been reprimanded or had probationary status? Yes 2. Has your license to practice your profession (optometry, medicine, etc.) in any jurisdiction ever been suspended, or revoked? Yes 3. Have your privileges at any hospital or institution ever been suspended, diminished, revoked, or not renewed? Yes 4. Have you ever been denied membership or renewal thereof, or been subject to disciplinary action in any optometric, medical organization or other agency? Yes 5. Have you been named in a malpractice action within the last two years? Yes 6. Has your employer been sued for your actions or has any formal or informal claim been made against you? Yes 7. Have any disciplinary actions or investigations been initiated, or any pending, against you by any state licensing board? Yes 8. Have you ever been the subject of disciplinary proceedings or investigations at any hospital or health care facility? Yes 9. Has your registration with the DEA or a state controlled substance agency ever been suspended or revoked? Yes Application for Clinical Privileges/ Illinois Eye Institute 6
SECTION TWO CATEGORIES OF CLINICAL PRIVILEGES Privileges for the professional staff and clinical staff of the Illinois Eye Institute are categorized according to the needs of specific patient populations and the levels of complexity in the management of vision, ocular and adnexal disorders as well as rehabilitative strategies. Each category requires a corresponding level of education, training, experience and/or credentials to assure quality care is provided to each patient. For all categories of privileges, the clinician may serve as a consultant, but is expected to request further consultation when: - he/she does not have the necessary privileges to provide the appropriate patient care management, or - the diagnosis and/or management remains in doubt over an excessive period of time, or - unexpected complications arise during the course of management which require care outside the level of privileges granted to the clinician. The applicant should identify each of the privileges that they are requesting on the following pages. Overview: Categories of Privileges and Brief Descriptions: Please see full Manual for further details. Category I This category of entry level privileges pertains to the care of patients in the diagnosis and management of vision disorders, diseases and conditions of the eye and adnexa. Some level of supervision may be provided/recommended along with these privileges. This category may also pertain to individuals who have not actively participated in patient care (of a similar population as their IEI assignment) for an extended period of time (typically years or as defined by the PSB). Category II This category of privileges pertains to the diagnosis and management of vision disorders, diseases and conditions of the eye and adnexa which require clinical skills developed during post-graduate training programs or as a consequence of clinical experience. Category III This category of privileges pertains to the diagnosis and management of vision disorders, diseases and conditions of the eye and adnexa which require an exceptional degree of expertise to manage and an inherent assumption of greater risk. Such advanced competency in eye and vision care can be recognized through Diplomate (AAO) certification, membership in national organizations or by demonstration of a recognized proficiency through extensive clinical experience, along with corresponding research, publishing and lecturing in the topic of specialty as well as serving as a referral source to independently manage those more complex patient encounters. Clinical Staff This category of privileges is for individuals who provide eye exams directly to IEI patients (internally and externally) under a variety of clinical and contractual arrangements and who do not/will not have a full time ICO faculty appointment and pertains to the care of patients in the diagnosis and management of vision disorders, diseases and conditions of the eye and adnexa. Credentials should be consistent with the population(s) being cared for. Application for Clinical Privileges/ Illinois Eye Institute 7
Requested Clinical Privileges: Name: _ Date: Category I Category II Primary Eye Care Primary Eye Care Teaching Binocular Vision Cornea and Contact Lens Working Towards Residency Certificate: Low Vision Rehabilitation Binocular Vision Ocular Disease Cornea and Contact Lens Teaching Low Vision Rehabilitation Ocular Disease Category III Clinical Staff Primary Eye Care Primary Eye Care Binocular Vision Binocular Vision Cornea and Contact Lens Cornea and Contact Lens Low Vision Rehabilitation Low Vision Rehabilitation Ocular Disease Ocular Disease Teaching Application for Clinical Privileges/ Illinois Eye Institute 8
SECTION THREE CONSENT AND RELEASE I acknowledge and agree that the Illinois Eye Institute and agents working on its behalf have a valid legal interest and requirement to obtain and verify information concerning my professional competence. Therefore: 1. I authorize the Illinois Eye Institute to consult with and to share credentialing information with administrators, malpractice carriers, third party payers, licensing boards and accreditation bodies. I also release Illinois Eye Institute representatives from liability for so doing; 2. I authorize the release by any person or entity to the Illinois Eye Institute all information and/or documents that may be relevant to any verification or evaluation of information or material relating to any disciplinary action, professional competence, suspension or reduction of clinical privileges. This may also include malpractice insurance my professional competence, character and ethical qualifications, including any and/or all claims. I release any person providing such information in good faith from any claims that I may have now or in the future; 3. I understand that the Illinois Eye Institute will make requests for the verification of information about me. If replies are not received in a reasonable amount of time, I will be notified and it will be my responsibility to assure that the information is forwarded to the Illinois Eye Institute, 4. I release from any liability and promise not to file suit and/or pursue any other remedies against any Illinois Eye Institute representatives for their evaluation of me and my credentials; 5. I understand that it is my responsibility to report any changes that affect my professional status or my ability to safely and competently perform my duties to the Illinois Eye Institute as soon as possible; 6. I understand that it is my responsibility to report any professional liability actions to the Illinois Eye Institute as soon as possible, 7. I have given complete, true and accurate information in this application. I understand that any misrepresentation by omission or affirmative statements shall be grounds for termination of my clinical appointment; 8. I signify that I understand the current credentials manual, and hereby agree to abide by their provisions in regard to my application for clinical privileges to the Illinois Eye Institute s attending staff. Print Applicant Name Applicant Signature Date Application for Clinical Privileges/ Illinois Eye Institute 9
SECTION FOUR APPLICATION CHECKLIST Name: Privileges applying for: 1. 2. 3. 4. I have enclosed the following: Yes No N/A expected date if No Application with Current Curriculum Vitae Current Illinois license; ancillary, if applicable Current Illinois Controlled Substance certificate Current DEA Registration Current CPR certification Malpractice certificate, if applicable Professional diploma(s) Residency certificate, if applicable Diplomate certificate, if applicable Fellowship certificate, if applicable Board certification, if applicable Continuing Education Certificates (For the last license renewal period ) Supporting documentation for additional privileges Signed release *Please include this checklist with your application **Keep a copy of your entire application for your records Application for Clinical Privileges/ Illinois Eye Institute 10