CREDENTIALING & PRIVILEGING PRE-APPLICATION DENTISTS, PHYSICIANS AND CERTIFIED REGISTERED NURSE ANESTHETISTS

CREDENTIALING & PRIVILEGING PRE-APPLICATION DENTISTS, PHYSICIANS AND CERTIFIED REGISTERED NURSE ANESTHETISTS

August 29, 2017 Dear Applicant, We appreciate your interest in becoming a part of Valleygate Dental Surgery Centers. Prior to beginning your service with Valleygate you must complete our credentialing process and be approved by our credentialing committee. Our credentialing policy is compliant with AAAHC standards. Our Privileging applies to Dentists, Physicians and CRNA s (licensed independent healthcare practitioners) who wish to provide services in any of our Valleygate Dental Surgery Centers. All interested clinicians will receive a Pre-Application and qualified applicants will receive a full application for clinical privileges. We have streamlined our process and will make every effort to process your application in a timely and efficient manner. The credentialing process consists of six-steps, which are as follows: Step 1: Applicant will submit a pre-application Step 2: Applicant will receive the applicant packet. Step 3: Applicant will return completed applications along with requested documents. Step 4: Application will be reviewed and processed by our Credentialing Specialist to make sure all information is complete and accurate and verified with the appropriate third parties. Step 5: The completed applicant packet will be forwarded to the Dental Director and reviewed by the Credentialing Committee. Their recommendation will be forwarded to the Chief Operating Officer for final approval. Step 6. Applicant will be notified of result. Although we will do everything to ensure there are no delays, the credentialing process may take up to 60 days to verify, review, and obtain final approval. To expedite the process, your application should be without blanks or missing requested documents; if anything is missing, the process will be delayed. If at any time, you have questions please contact the Dental Director or Compliance Officer at Valleygate so we may resolve any problems prior to submission. Our goal is to assist you while ensuring that we are compliant with the Accreditation Association for Ambulatory Health Care (AAAHC) and other relevant guidelines. Sincerely, Erica Kennerson Compliance Officer Valleygate Dental Surgery Centers Dr F McGibbon Dental Director Valleygate Dental Surgery Center of Fayetteville Dr A Dodds Dental Director Valleygate Dental Surgery Center of Greensboro Email: ekennerson@vfdental.com Email: FMcGibbon@vfdental.com Email: doddsap@earthlink.net

Pre-Application The applicant must state his/her intention for application. The pre-application will be forwarded to the Dental Director and the Chief Operating Officer. If approved, the full application privilege forms will be mailed to the applicant. If the Applicant s pre-application does not meet the requirements for becoming an LIP of the Facility or indicates that the Facility is unable to accommodate the Applicant, then the Applicant shall be informed of this in writing within fourteen (14) days from the date the pre-application is stamped received. Fayetteville Greensboro Charlotte I A. PERSONAL INFORMATION 2. Name (Last, First, Middle) Degree/Professional Title 3. 4. Gender: Male Female Other Names You May Have Used (Maiden, a.k.a., etc.) 5. 6. Home Address/Street City/State/Zip 7. 8. 9. Home Telephone No. Home Fax No. E-mail Address 10. 1 Date of Birth (Month/Day/Year) Citizenship/Place of Birth 12. 13. Languages fluently spoken (in addition to English) Languages written in addition to English 14. 15. Social Security No. Ethnicity (Optional) 16. If you are not a US Citizen do you have authorization to work in the US? 17. NPI number Medicare number Medicaid number I B. PRACTICE SPECIALTY FOR WHICH YOU ARE SEEKING AFFILIATION Are you applying as a: Pediatric Dentist Oral Surgeon General dentist Anesthesiologist CRNA Other II. PROFESSIONAL SCHOOL List all Dental/ Medical/Professional Schools/Institutions attended including undergraduate and graduate school for CRNA s. Enclose copies of your diplomas and certificates. Dental /Medical/Professional School Degree Awarded Date of Graduation (mm/yy) 2. Dental /Professional School Degree Awarded Date of Graduation (mm/yy)

III. POST GRADUATE TRAINING INTERNSHIP Program successfully completed? 2. RESIDENCY Program successfully completed? 3. FELLOWSHIP Program successfully completed? IV. HOSPITAL / FACILITY HISTORY CURRENT Primary Admitting Facility Dates From (mm/yyyy) Dates To (mm/yyyy) Address Suite City State Zip Department/Specialty Staff Category Chairperson Telephone No. V. WORK HISTORY Current Practice Contact Name Dates From (mm/yyyy) Dates To (mm/yyyy) Address Suite City State Zip Telephone No. If at current practice/hospital for less than three years please include information regarding previous employer 2. Previous Practice Contact Name Dates From (mm/yyyy) Dates To (mm/yyyy) Address Suite City State Zip Telephone No.

VI. OTHER DISCLOSURES Please answer all of the following: Has your license to practice dentistry/medicine in any jurisdiction ever been voluntarily or involuntarily suspended, limited, revoked, or sanctioned in any way? 2. Have you ever been denied a license to practice dentistry/medicine? 4. Have you ever had a request for a specific clinical privilege denied? 5. Have you ever been suspended, voluntarily or involuntarily sanctioned, or otherwise restricted from participating in any private, federal, or state health insurance program? 7. Has your federal narcotics registration (DEA) ever been voluntarily or involuntarily suspended or revoked? 9. Have you ever been the subject of any disciplinary proceedings at any healthcare facility, to include behavior deemed inappropriate? 10. Have you ever been convicted of or pled guilty to or entered into a plea agreement for a violation of any law or ordinance other than traffic offenses, but including driving while under the influence of alcohol or any other substance? 1 Have you ever been denied professional liability insurance? 13. Have any professional liability suits ever been filed against you? 14. Have any professional liability suits filed against you resulted in judgment against you or been terminated pursuant to a settlement in which you have paid damages to the plaintiff with or without admitting liability? 15. Have you ever settled any professional liability claim against you prior to suit and admitted liability as a part of such settlement? 16. Has any claim of sexual harassment or violation of civil rights ever been made against you that resulted in your receiving or incurring any warning, disciplinary action, or civil liability? 17. Have you ever enrolled or are you currently enrolled in a structured assistance program designed to help deal with substance abuse or behavior problems? Applicant s Signature: Print Name: Date: Return Form by Mail to: Valleygate Dental Surgery Centers ATTN: Erica Kennerson 2015 Valleygate Drive Fayetteville, NC 28304 Email to: ekennerson@vfdental.com In-person to: 2015 Valleygate Drive, Fayetteville, NC 28304 (In sealed envelope with ATTN: Erica Kennerson)