[ ] My application is in connection with a Professional Services Agreement (PSA), please indicate name of PSA:

I am applying to following UNM Health System Entity (s): [ ] [ ] Please select category you would like to apply to: [ ] Active [ ] Courtesy [ ] Consulting [ ] Telemedicine [ ] Ambulatory [ ] Allied Health [ ] ALSO - Please check the applicable credentialing entry point: [ ] I am/will be employed by the following UNM Health System employer (may include Faculty volunteers): UNM* UNMH SRMC UNMMG *Includes: School of Medicine, College of Pharmacy, College of Nursing, and UNM Human Resources [ ] My application is in connection with a Professional Services Agreement (PSA), please indicate name of PSA: [ ] I am applying as a Community Provider (SRMC only) Please Note: Signature stamps and date stamps are not acceptable. All applicants have the right to be informed of their application status. Application status inquiries should be directed to the UNM Health System CVO. Practitioners may utilize any or all of the following to ensure accurate file information: The right of practitioners to review information submitted to support their credentialing application. The right of practitioners to correct erroneous information. The right of practitioners to be informed of the status of their credentialing or recredentialing application upon request. The right of practitioners to be notified of these rights. 1

Attach Photo Date of Application: Name: Last First Middle Maiden or Other Names Used Circle all that apply and for which you are currently licensed: MD DO DDS DPM Clin Psych OD PA CNM CNP CRNA AA CNS DOM DC PT OT SLP LMT LD LPAT LISW LMSW LPCC LMFT Rph RDH Other: Specialty: Gender: Female Male Transgender Place of Birth: Social Security Number: Date of Birth: State Tax ID#: Pending Federal Tax ID#: Pending Medicare #: Pending Medicaid #: Pending National Provider Identifier Number (NPI): Applied Home Address: City, State/Province and Zip Code: Cell Phone Number: Credentials Correspondence Address: Department/Name: City, State/Province and Zip Code: Email Address: Pager Number: Applicant Email: Facsimile Number: Military Service: Branch: Dates: From: To: Rank: Type of Discharge: Citizenship/Immigration: Status: Immigration Certification Number (if applicable: ECFMG (Educational Commission for Foreign Medical Graduates) Number (if applicable): Date Issued: (Please attach a copy of your ECFMG certificate.} 2

Languages: Foreign Languages (spoken fluently by practitioner): Certifications: ACLS CERTIFICATION ATLS CERTIFICATION PALS CERTIFICATION Certified: Certified: Certified: Expires: Expires: Expires: HOSPITAL AND HEALTHCARE AFFILIATIONS Please list all hospital staff membership and/or healthcare organization affiliations, and your status (active, courtesy, consulting, etc.). If an institution is no longer in existence, please provide an alternative source of verification. Use a separate page, if necessary. Current Primary Admitting Facility (Hospital Name): Facsimile: Appointment Dates: From: To: Present Type of Appointment: Privileges Assigned: Department Chair/Division Chief: Phone: Fax: Email Address: Facility Name: Facsimile: Appointment Dates: From: To: Present Type of Appointment: Privileges Assigned: Facility Name: Facsimile: Appointment Dates: From: To: Present Type of Appointment: Privileges Assigned: Facility Name: Facsimile: Appointment Dates: From: To: Present Type of Appointment: Privileges Assigned: 3

WORK HISTORY Please list all previous experience, including months and years, listing the most recent first. Attach a separate page if necessary. Please attach a current CV or resume. Organization: From: / To: / Present Contact Person: Type of Practice: Organization: From: / To: / Present Contact Person: Type of Practice: Organization: From: / To: / Present Contact Person: Type of Practice: Department Chair/Division Chief: Organization: From: / To: / Present Contact Person: Type of Practice: Department Chair/Division Chief: Organization: From: / To: / Present Contact Person: Type of Practice: Department Chair/Division Chief: Please provide a written explanation for any gaps in work history of two (2) months or more. 4

PRACTICE LOCATIONS Primary Practice/Group Name: Effective Date: City, State/Province and Zip Code: Facsimile Number: E-Mail Address: Answering Service Number: Foreign Languages (spoken fluently at practice): Office Manager or Contact Person: Billing Address: Same as above Contact Person: Tax ID #: City, State/Province and Zip Code: Facsimile Number: Practice Associates: Call Coverage (if different): / / / / What are the office hours for your Practice or Group Practice? (Provide days/hours): What provisions have been made for after hours? Other Practice Locations: (Attach a separate page for additional practice locations.) Practice Name: Tax ID #: City, State/Province and Zip Code: Facsimile Number: 5

CLINICAL COMPETENCE DESIGNATION As part of the credentialing process, we are required by regulation to verify an applicants current clinical competence for privileges requested. As defined below, please provide the name of the source who can verify your current clinical competence. Your Status (check all that apply) New Graduate (in practice as an attending for less than 3 years) - if a new graduate, provide the name and contact information for the: Clinical Competence Source Program Director (of your Residency Program or Fellowship Program if at least 3 years in duration and required for practice within your Specialty) Attending Physician - if currently practicing as an attending in a hospital setting, provide the name and contact information for the: Department Chairman or Division Chief (of your Primary facility) Physician practicing outside of the Hospital Setting (i.e. private office based practice, outpatient clinic only, etc.) - if currently practicing outside of the Hospital Setting, provide the name and contact information for the: Person to whom you currently report NOTE: The individual listed below should not be listed as a Peer Reference on the Credentialing Information Form. If you are unsure of whom to designate, please contact the Medical Staff Office at the facility where you are applying. Source Name (First Middle Last, Degree): Facsimile: Email: *This information is a mandatory part of your credentialing process if the information is not returned, your application will not be processed until information is received. 6

PROFESSIONAL REFERENCES Please list five (5) professional peers with the same type of license, or a higher level of licensure, who are familiar with your professional performance in the past two (2) years. 1) Name and Title: Specialty: Email: Facsimile: 2) Name and Title: Specialty: Email: Facsimile: 3) Name and Title: Specialty: Email: Facsimile: 4) Name and Title: Specialty: Email: Facsimile: 5) Name and Title: Specialty: Email: Facsimile: LICENSURE REGISTRATION INFORMATION List all licenses held in all jurisdictions. Attach a separate page, if necessary. State Professional License/Certification Number: State: Issue Date: Expiration Date: State Professional License/Certification Number: State: Issue Date: Expiration Date: State Professional License/Certification Number: State: Issue Date: Expiration Date: Pending Pending Pending State Controlled Substance Registration (CSR): DRUG CERTIFICATION INFORMATION Federal Drug Enforcement Administration (DEA) Registration: N/A DEA Number: Expiration Date: State: Pending N/A 7

CSR Number: Expiration Date: State: Pending EDUCATION List all medical, osteopathic, dental or podiatric schools attended for graduate education and list all hospitals where you received training for post-graduate training. Attach a copy of your certificate. Disclose every residency program initiated, whether completed or not, and all completed programs. Attach a separate page, if necessary) Check the type of education listed. Undergraduate Graduate Post Graduate Internship Residency Fellowship Teaching position Institution: Dates Attended: From: / To: / City, State/Province, Country, Zip: Graduation Year: Degree Earned: or Specialty: If teaching appointment: Department/Position: Training Program Director: Phone: Fax: Email Address: Undergraduate Graduate Post Graduate Internship Residency Fellowship Teaching position Institution: Dates Attended: From: / To: / City, State/Province, Country, Zip: Graduation Year: Degree Earned: or Specialty: If teaching appointment: Department/Position: Training Program Director: Phone: Fax: Email Address: Undergraduate Graduate Post Graduate Internship Residency Fellowship Teaching position Institution: Dates Attended: From: / To: / City, State/Province, Country, Zip: Graduation Year: Degree Earned: or Specialty: If teaching appointment: Department/Position: Training Program Director: Phone: Fax: Email Address: Undergraduate Graduate Post Graduate Internship Residency Fellowship Teaching position Institution: Dates Attended: From: / To: / City, State/Province, Country, Zip: Graduation Year: Degree Earned: or Specialty: If teaching appointment: Department/Position: Training Program Director: Phone: Fax: Email Address: 8

SPECIALTY BOARD CERTIFICATIONS If you are not Board certified by a Board recognized by the American Board of Medical Specialties, the American Osteopathic Association, and the National Commission on Certification of Physician Assistants, the American Nurses Credentialing Center, or the National Certification Commission, or accepted by examination in your specialty, please provide an explanation below. Explain any gaps or delays in achieving Board certification by the recognized Board in your specialty area. Board or Specialty or Subspecialty Date Certified: Date Last Recertified: Expiration Date: N/A Certification Number: Accepted for Examination Expiration Date: If not accepted, have you made application? If no, provide an explanation: Board or Specialty or Subspecialty Date Certified: Date Last Recertified: Expiration Date: N/A Certification Number: Accepted for Examination Expiration Date: If not accepted, have you made application? If no, provide an explanation: Board or Specialty or Subspecialty Date Certified: Date Last Recertified: Expiration Date: N/A Certification Number: Accepted for Examination Expiration Date: If not accepted, have you made application? If no, provide an explanation: Board or Specialty or Subspecialty Date Certified: Date Last Recertified: Expiration Date: N/A Certification Number: Accepted for Examination Expiration Date: If not accepted, have you made application? If no, provide an explanation: MEDICAL MALPRACTICE INSURANCE Do you have current medical malpractice insurance? Please list medical malpractice insurance carriers for the past five (5) years. Attach a separate page, if necessary. Current Carrier: 9 Limits: Current Pending Dates Insured: From: To: Policy Number: Carrier: Limits: Dates Insured: From: To: Policy Number:

PROFESSIONAL PRACTICE QUESTIONS Please answer the following Yes or No questions. Note that N/A is not an acceptable response except for question #16. If you answer YES to any question, you must give details including name, address, and telephone number of significant parties on a separate sheet of paper. You must respond to each question. 1. Has your professional liability coverage ever been terminated by action of the insurance company (except as a result of the company ceasing to offer insurance coverage to physicians or other practitioners)? 2. Have you ever been denied professional liability insurance coverage? 3. Has your professional liability carrier ever excluded any specific procedures from your coverage? 4. Have you ever been denied membership or renewal thereof, or been subject to disciplinary action in any professional organization? 5. Have you ever had any sanctions imposed by Medicare and/or Medicaid? 6. Have you ever been convicted of a misdemeanor or felony (excluding minor traffic violations) in the United States or any crime in another country? 7. Have you ever been arrested, indicted, charged, or been a defendant in a trial, regardless of the outcome, of any crime involving: Intoxication Illegal use, possession or distribution of an illegal substance Trafficking of DEA Schedule II drugs Sexual offenses Domestic violence; or Harm to a minor 8. Have you ever been subject to investigation by a governmental entity or licensing board that could have resulted, or did result, in licensure sanctions or other adverse actions, irrespective of the outcome? 9. Has your application for licensure or license to practice in any jurisdiction ever been investigated, voluntarily or involuntarily limited, suspended, revoked, surrendered, or denied? 10. Are any currently held licenses pending investigation or being challenged? 11. Have you ever been notified to appear before any licensing agency for a hearing or complaint of any nature? 12. Have you ever been named in any formal requests for corrective actions filed by any healthcare entity where you have had an appointment (a request which could result in either formal or informal proceedings)? 13. Have your privileges at any healthcare entity ever been voluntarily or involuntarily suspended, restricted, diminished, revoked or not renewed, except for medical records delinquency? 14. Have you ever agreed not to exercise your clinical privileges while under investigation? 15. Have you ever resigned from a healthcare entity while under investigation for or to avoid modification, suspension, or termination of privileges? 16. Has your federal or state narcotics registration certificate in any jurisdiction ever been voluntarily or involuntarily limited (stipulations), suspended, revoked, restricted, or surrendered, or is it currently being challenged? Yes No N/A 10

17. Have you ever been involved in a settlement, medical malpractice claim or suit, or have you ever received written notice of intent to file such a suit? If yes, please provide the following information for each claim or suit. Please list on a separate sheet of paper for each case: Name, age, sex of patient/claimant. Date(s) and type of treatment and/or surgery that led to the allegations against you. Nature of allegations in claims/suits. Specify whether a suit was ever filed. Names of other practitioners and hospital, if any, involved in claims or suit. Disposition or current status of claim or suit (be specific). Name of insurance carrier defending you. Name of defense attorney. 18. Do you know of any reason why you cannot perform the essential duties of the clinical privileges/functions which you are requesting, with or without a reasonable accommodation according to acceptable standards of professional performance and without posing a direct threat to patients? 19. Do you use illegal drugs or have you illegally used drugs in the past five years? 20. Are you now, or were you in the past, addicted to, abusive of, or in treatment for abuse of any controlled substances, habit-forming drugs, prescription medication or alcohol? 21. Have you ever, for any reason: a. Resigned from or withdrawn from a medical or professional school or postgraduate training program? b. Been suspended, dismissed, or expelled from a medical or professional school or postgraduate training program? c. Been placed on probation or remediation, including academic probation or remediation, by a medical or professional school or postgraduate training program? d. Taken a leave of absence or break from, or had any interruptions or extensions in, a medical or professional school or postgraduate training program for any reason, personal or professional (including illness or disability, pregnancy or maternity, any academic issues, or other similar reasons)? Yes Yes Yes Yes No No No No Addendum Questions: Are you subject to mobilization as a member of a reserve or Guard unit, as an individual mobilization augmentee, or subject to recall to active duty as a retired military provider? Yes No If Yes to above, what is your PRESENT status? What Service Branch applies? Active Reserve Active National Guard Retired Reserve Retired Regular Retired National Guard US Army US Navy Army National Guard US Coast Guard US Air Force US Marine Corp Air National Guard In the last twelve (12) months, were you employed in a managerial, accounting, auditing, or similar capacity by an agency organization which is responsible directly or indirectly for decisions regarding Department of Defense payments to you or to your practice? Yes No 11

MALPRACTICE CLAIMS HISTORY (See Page 11, question 17) N/A If applicable, please copy this addendum form for each additional claim. Failure to complete this form in its entirety will result in a delay in processing of your application.) Name of Practitioner: Name and Age of Claimant: Date and Location of Facility where Incident Occurred: Date Lawsuit Filed: Name of Court and Case Number: Case History of Patient Care / Describe your involvement: Alleged Malpractice: Patient Outcome: Status of the Case: (with reference to you, specifically) Pending Dismissed Date: Denied Date: Closed Without Payment Date: Pre-Trial Settlement ($ ) Date: Settlement ($ ) Date: Verdict for Defendant ($ ) Date: Verdict for Plaintiff ($ ) Date: Medical Legal Panel Decision: Votes in Favor Votes Against Name, phone #, Fax # & address, of insurance carrier: Name, phone #, Fax# & address of defense attorney: Provide any names and phone numbers of others who could provide additional information regarding this claim/suit: 12

CONTINUING MEDICAL EDUCATION RECORD Practitioner: License: Dates: (Time frame covers initial appointment requirement or reappointment period, as appropriate) Completion Date Provider # Course Name Contact Hours ATTESTATION STATEMENT I have successfully completed the hours of continuing education, with a minimum of 50% obtained within my scope of practice, within the past two years. I acknowledge that the State of New Mexico Medical Board has Mandated CME participation to maintain a DEA license and I have met the requirements as specified by the state. I declare under penalty of perjury under the laws of the state of New Mexico that the foregoing is true and correct. I agree to provide proof of attendance and program content upon request. Signature: Date: 13

UNM Health System (Includes UNM Hospitals, UNM Sandoval Regional Medical Center, Inc., UNM Medical Group, Inc., UNM Health) Attestation/Consent For New Applicants & Reappointment Applicants A. I certify that the information and documents I have provided to the UNM Health System, in and with this application, in connection with my credentialing appointment or reappointment application are current, correct, true, and complete to the best of my knowledge. If another person has completed any part of this application, I certify that I have reviewed such information and confirm it is current, correct, true and complete. I fully acknowledge and understand that the University of New Mexico and the UNM Health System are relying upon accuracy and completeness of the information in considering the application. I therefore acknowledge, understand, and agree that any material misstatement in or omission from the application will constitute good and adequate cause for denial or revocation of membership/clinical privileges at any UNM Health System component and/or will jeopardize my participation in UNM Health plan contracts. I understand that any material misstatement or omission may be grounds for reporting me to the New Mexico Medical Board or applicable New Mexico licensing board. B. By filing this application for membership or clinical privileges at any UNM Health System component and/or for participation in UNM Health plan contracts, I acknowledge that I have received, read, and fully understand the Medical Staff Bylaws, rules and regulations, and policies for each respective facility I seek to join. I agree to be bound by the terms of each respective Medical Staff Bylaws, rules and regulations, and policies in all matters relating to the consideration of my application, regardless of whether I am granted appointment or reappointment to the medical staff or membership as an allied health professional/other healthcare practitioner. I further agree that, in the event there should arise an adverse recommendation or ruling with respect to my status, application and/or clinical privileges, I will fully exhaust the administrative remedies afforded by the terms of each respective facilities bylaws, rules and regulations, and policies before resorting to litigation. C. I understand that appointment/reappointment to the medical staff and the granting or renewal/revision of clinical privileges are made for a period of not more than two (2) years at which time I must submit a new application for renewal of privileges, which will be based on a reappraisal at the time of reappointment and/or renewal or revision of clinical privileges. In the event I am granted privileges, I agree that I will provide for continuous care for my patients and to arrange for appropriate back up and call coverage for my patients. D. I understand that the medical staff of the respective UNM Health System facility is responsible for the evaluation of my professional competence and qualifications and has the obligation to inquire into my professional training, experience, conduct and judgment, and to make recommendations to the governing body of the respective UNM Health System facility as to whether to grant me membership on the medical staff and privileges associated therewith. I acknowledge that peer recommendations are part of the basis for the development of recommendations for appointment or reappointment to the medical staff and the initial granting or renewal/revision of clinical privileges. I understand that the Office of Clinical Affairs will review my professional criteria, including but not limited to evidence of my current licensure, relevant training and/or experience, current competence, and health status. E. I hereby consent to and authorize the Office of Clinical Affairs to request, receive, review, and compile information, data and documents pertinent to my status, privileges, competence, qualifications, education, training, professional and clinical ability, malpractice history, character, conduct, ethics, judgment, mental and physical health status, emotional stability, utilization practices, professional licensure or certification, and any other matter related to my qualifications or matters addressed in the application. I also authorize the Office of Clinical Affairs to exchange or disseminate this information for credentialing purposes. 14

F. I authorize the UNM Health System and the Office of Clinical Affairs to release such information, on a continuing basis and as needed, to other organizations, health care facilities, managed care entities, and their agents, who solicit such information for the purpose of evaluating my qualifications pursuant to a request for appointment and clinical privileges, participating provider status or other credentialing matter. This includes release of such information during the interim between appointment and reappointment for credentialing and peer review purposes, such as for ongoing professional practice evaluation. G. I authorize UNM Health System affiliated hospitals and provider entities for which I am an appointee or applicant for appointment, including the medical staffs and authorized representatives of the foregoing, to release to one another and share with one another any information that bears on my professional qualifications, credentials, clinical competence, character, ability to perform safely and competently, ethics, or professional conduct. This authorization includes the right to inspect or obtain any communications, reports, records, statements, documents, recommendations or disclosures bearing on such matters. H. I understand and agree that I, as an applicant for medical staff membership or credentialing, ha ve the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubt of such qualifications. I will provide any information or documents as may be requested by the Office of Clinical Affairs, which may be requested to answer any questions or resolve any issues concerning my clinical competence or conduct, and I will appear for interviews regarding my application if requested. I. During such time as this application is being processed, I agree to update the application should there be any change or supplement to any of the information or documents provided which may affect the application or its outcome. I fully understand that any failure to provide complete and accurate information, any significant misstatement in or omission from this application, or any such failure, misstatement or omission at any time during the appointment or reappointment process, constitutes cause for denial of appointment or, if the failure, misstatement or omission is discovered after I am appointed or reappointed, cause for summary dismissal from the professional staff, or a denial or a revocation of clinical privileges at any UNM Health System facility and/or participation in UNM health plan contracts. J. In consideration for the acceptance of my application and the undertaking to verify and process my application, I hereby release and hold harmless any and all persons or entities that provide information, including but not limited to the Federation of State Medical Boards of the United States, Inc., the National Practitioner Data Bank, hospitals, licensure boards, insurance companies and health plans, of and from any claim, cause of action, liabilities, damages (including attorney s fees) to the fullest extent allowed by applicable statutes, regulations and judicial decisions arising out of or relating to the provisions of Information to the University in connection with the Application. Furthermore, I also hereby release and hold harmless the Regents of the University of New Mexico, its Health Sciences Center, UNM Sandoval Regional Medical Center, Inc., UNM Medical Group, Inc., UNM Health, the Office of Clinical Affairs, each respective medical staff, and all officers, employees and agents of the aforementioned entities from any claim, cause of action, liabilities, damages (including attorney s fees) arising out of, or relating to, any information or data concerning my performance as a member of the medical staff any of the hospitals or clinics affiliated with the University of New Mexico, UNM Sandoval Regional Medical Center, Inc., UNM Medical Group, Inc., UNM Health to third parties requesting the same in connection with provider credentialing at such institution, health plan, or insurance provider or agents thereof. This Attestation/Consent shall be privileged to t he fullest extent permitted by law. If accepted for appointment/reappointment, I pledge to provide for the continuous medical care of my patients as assigned. Print Name Signature Date 15

MEDICARE ACKNOWLEDGEMENT STATEMENT Notice to Physicians: Medicare payment to hospitals is based on part on each patient s principal and secondary diagnosis, and the major procedure 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 applicable federal laws. Provider Signature Date Provider Name (please print) Rev: 1/27/14 16

PROVIDER PERFORMED LABORATORY TESTING INSTRUCTIONS Clinical Laboratory Improvement Amendments (CLIA) requires every facility that tests human specimens for the purpose of diagnosis, prevention, treatment, or the assessment of the health of a human being to meet certain Federal requirements. All testing named in the three sections below (waived, non-waived microscopy, and instrument based testing performed by providers) must follow the CLIA requirements. CLIA regulations apply even if only one or a few basic tests are performed, and even if you are not charging for the testing. Failure to follow these requirements could be grounds to revoke an individual site s CLIA license and that site would be unable to perform any laboratory testing. To maintain compliance with all CLIA regulations for providers we are using the credentialing process. Please complete the Demographics section of page 1 and sign the appropriate sections of testing that you currently perform in the scope of your practice. If you do not perform any testing, then sign the last section entitled, Non-Testing Statement. DEMOGRAPHICS Applying to: Name (Please Print): UNMH SRMC UNMMG Department Site: Email: Phone: Pager: WAIVED TESTING If you are a Licensed Independent Practitioner I have been trained and am competent to perform the following waived testing: Occult blood, fecal and gastric Urine Dipstick Urine Drug ph paper Urine Pregnancy Signature: Date: *If you will be performing these tests and would like additional training please contact the Point-of-Care Office at 272-0980. If you are not a Licensed Independent Practitioner I understand that I must be trained, observed and participate in a written exam for all waived testing that I perform. Both the observed and written exam must be completed upon training and annually thereafter. Please contact the Point-of-Care Office at 272-0980 to schedule training. Signature: Date: Rev: 1/27/14 17

NON-WAIVED MICROSCOPY TESTING I have been trained and am competent for the following Non-Waived Microscopic tests which I expect to perform in my course of work: Vaginal pool fluid smears for ferning Pinworm examination Potassium hydroxide (KOH) preparations Urine sediment microscopy Vaginal wet mount microscopy Other (please describe): Providers that perform microscopy will be required to complete a competency test every six (6) months. They will receive an email from MTS (University of Washington) with an internet link to begin the online competency. Each test type takes approximately 2 minutes to complete. Signature: Date: Should you not successfully complete the online competency on this 6 month basis the medical director of the clinic site and department chair will be notified. If you are continuing to perform testing this would be testing outside of CLIA regulations and could jeopardize the site s CLIA license and any staff s ability to do any testing at all. Should you need additional training for these tests please contact the medical director of your site. INSTRUMENT BASED AND/OR NON-WAIVED TESTING I understand that I must be observed and participate in a written exam for all instrument based testing or nonwaived testing that I perform. Both the observed and written exam must be completed upon training, at 6 months, at 1 year and annually thereafter. Waived and non-waived testing is treated no different if performed on an instrument. This includes, but is not limited to the following testing: AVOXimeter Co-Oximetry Clinitek Automated Urine Dipstick reader Radiometer ABL 90 Blood Gas & Chemistry analyzer Hemochron Signature Elite ACT Hemocue Hemoglobin I-Stat Blood Gas & Chemistries Coaguchek XS Plus PT/INR Accuchek Inform Glucose VerifyNow Platelet Function Refractometer Specific Gravity Should you wish to perform these tests please contact the Point-of-Care Office at 994-7139 for initial training and a testing barcode. Signature: Date: NON-TESTING STATEMENT I acknowledge that I do not perform any point-of-care testing. Signature: Date: Rev: 1/27/14 18