NorthwestHospital & MedicalCenter
Seattle, Washington
Physician Supplement to Washington Practitioner Application
ACKNOWLEDGMENTS AND AGREEMENTS
Your signature below certifies your acknowledgment of and agreement to the following:
a.Continuing Obligation to Report
You will fully report all relevant information to Northwest Hospital as soon as practical in the event any of the events indicated in questions 1 through 14 (i.e., if one of those questions must be answered "yes") after you have signed and dated this form while your application is pending and, if you are appointed to Medical Staff membership or granted privileges at this Hospital, while you have Medical Staff membership or privileges here.
b.You recognize that your appointment to membership on the Medical Staff of this Hospital and the granting of clinical privileges to you is dependent on professional competence and ethical practice in keeping with the qualifications, standards, and requirements set forth in the Medical Staff Bylaws and Rules and Regulations.
c.Additional Conditions of Continuing Medical Staff Membership and Clinic Privileges
You agree to maintain an ethical practice, to provide for continuous care of all your patients, and to abide by the Medical Staff Bylaws and Rules and Regulations of Northwest Hospital, and all laws, rules and regulations of applicable governmental entities.
YOU FULLY UNDERSTAND THAT ANY SIGNIFICANT MISSTATEMENTS IN OR OMISSIONS FROM THIS APPLICATION WILL CONSTITUTE CAUSE FOR DENIAL OF YOUR APPLICATION FOR APPOINTMENT, AND TERMINATION OF MEDICAL STAFF MEMBERSHIP AND CLINICAL PRIVILEGES. YOU HEREBY AFFIRM THAT THE INFORMATION FURNISHED BY YOU TO THE MEDICAL STAFF IS TRUE AND COMPLETE TO THE BEST OF YOUR KNOWLEDGE.
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Back-Up Call Coverage
NorthwestHospital Medical Staff Bylaws require documentation of Back-Up Call Coverage. Please note Back-Up Call Coverage may only be provided by Active, Courtesy and Provisional members of the Northwest Hospital Medical Staff with privileges in the same specialty. Please list those physicians who will be providing your Back-Up Call Coverage.
Physician Name: / Physician Name:Physician Name: / Physician Name:
Physician Name: / Physician Name:
Physician Name: / Physician Name:
Physician Name: / Physician Name:
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Medicare Physician Acknowledgement Statement
“Notice to Physicians: Medicare payment to hospitals is based in part on each patient’s principal and secondary diagnoses and the major procedures 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.”
I ACKNOWLEDGE RECEIPT OF THE ABOVE NOTIFICATION.
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Physician Name (PLEASE PRINT)
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Physician Signature
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The above acknowledgement will be filed in the physician’s credential file in the Medical Staff Office and will be made available to Qualis Health and/or CMS upon request.
Dear Applicant:
For your information, you can review the Bylaws of Northwest Hospital Medical Staff, as well as the HIV/HBV/HCV Positive Health Care Workers policy online at: .
You will be interested in:
A.Rights and Responsibilities of members of the Northwest Hospital Physician Active Staff. (Page 2, 1B)
B.Appointments and Privileges (Page 6, B)
- Basic Criteria for Membership (Page 8, 3, b)
D.Board Certification (Page 8, 3, b, iv)
E.Procedure Concerning Appointments and Privileges (Page 13, C)
Addendum I contains the Rules and Regulations that apply to all medical staff members.
Addendum II contains Statement of Functions & Responsibilities for Medical Staff Leadership.
Addendum III contains MEC/NWH HIPAA Resolution.
During our JCAHO survey in April 1999, the physician surveyor recommended we identify a process to document distribution of the Bylaws to the Medical Staff. To that end, we are requiring you sign this memo in the space provided below. Your signature on this letter will acknowledge your receipt of the Bylaws, Rules & Regulations, Statement of Functions & Responsibilities and HIPAA resolution, as well as the HIV/HBV/HCV Positive Health Care Workers policy. Your signature will also serve as attestation that you have reviewed the Bylaws, Rules & Regulations, Statement of Functions & Responsibilities and HIPAA resolution, as well as the HIV/HBV/HCV Positive Health Care Workers policy.
Any questions may be referred to me through the Medical Staff Office at (206) 368-1811.
Sincerely,
Hunter Hodge, MD, FACEP
Chief of Staff
By signing below, I acknowledge I have received the Northwest Hospital Medical Staff Bylaws, Medical Staff Rules & Regulations, Statement of Functions & Responsibilities and HIPAA Resolution dated May 3, 2011, as well as the HIV/HBV/HCV Positive Health Care Workers policy. I understand that by signing below, I am indicating I have reviewed the Bylaws, Rules & Regulations, Statement of Functions & Responsibilities and HIPAA resolution, as well as the HIV/HBV/HCV Positive Health Care Workers policy.
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