Medical Resident/Student
Allied Health Professional Student
Application Form
Please Type or Print Legibly
Name ______Dates of Rotation at SWMH______
Permanent Home Address: ______
Permanent Home Phone ______SSN ______
Training Program Affiliation: ______
Program Director Name and Phone Number: ______
Insurance Company: ______
Supervising Physician at Southwest Memorial Hospital: ______
Birth Date: ______Birthplace: ______Year in Training: ______
Applicant Category:
Emergency Medicine Resident/Student
Family Medicine Resident/Student
General Surgery Resident/Student
Internal Medicine Resident/Student
Allied Health Professional Student
NP
PA
- REQUIREMENTS -
1. A signed affiliation agreement between the Hospital and the school, to be kept in the Administrative Offices
2. Written verification from the training program/school that the individual is a participant in good standing
3. Documentation of malpractice insurance coverage in the amounts specified by the Hospital’s Governing Board
4. Documentation of registration with the Colorado State Board of Medicine
5. Written and signed verification from the supervising physician acknowledging responsibility for the resident/student
6. Documentation that the supervising physician is registered as such with the Colorado State Board of Medicine
7. Dates of clinical rotation
8. Documentation of health screening consistent with the Human resources/Education Department’s policies
9. Recent photo identification to verify identity, such as driver’s license or passport
10. Verification of clear, completed criminal background check (completed by Medical School, Residency Program or AHP Program)
11. Current Curriculum Vitae
12. Letter of successful completion from Medical School (Medical Residents only)
The application and all required documents and information must be fully completed, signed, and received by the Medical Staff Office before processing may begin. You will not be allowed to function at Southwest Memorial Hospital or any SWMH affiliate until this information has been received and verified as appropriate. Once the application has been approved the Medical Staff Office will notify hospital departments that the application is complete.
For each “yes” answer attach a written explanation.
Have any of the following at any time been, or are any currently in the process of being denied, revoked, sanctioned, not renewed, not completed, suspended, diminished, challenged, withdrawn, terminated, revoked, limited, restricted, placed on probation or other conditions, placed under disciplinary or investigative action or revoked either voluntarily or involuntarily in any jurisdiction or country?
· Medical or processional license ÿ Yes ÿ No
· Clinical privileges ÿ Yes ÿ No
· Application/Membership or other rights at any healthcare facility ÿ Yes ÿ No
· Employment by any hospital, institution, or the military ÿ Yes ÿ No
· Controlled Substance Registration ÿ Yes ÿ No
· Participation in any federal, state, or private health insurance program ÿ Yes ÿ No
· Participation in any HMO, PPO, or other managed care organization ÿ Yes ÿ No
1. Have you ever been convicted of a crime (felony or misdemeanor)? ÿYes ÿ No
2. Do you have any rehabilitation or other stipulations on your current license? ÿYes ÿ No
3. Are you presently the subject of any formal disciplinary proceedings at any ÿYes ÿ No
healthcare facility, physician organization, or professional organization?
4. Have you ever been sanctioned by any organization with responsibility ÿYes ÿ No
for overseeing the quality, ethics, appropriateness, or other professional
conduct of the medical profession?
5. Are you or have you ever been a party or defendant in any malpractice proceeding? ÿYes ÿ No
6. Have you ever been terminated from any medical school or post-graduate program? ÿYes ÿ No
- SCOPE OF PRACTICE –
1. Residents/Students shall be supervised by an attending physician/preceptor who is members in good standing of the Medical Staff.
2. Residents shall consult their attending physician/preceptor on all admissions and patients shall be seen by the attending physician/preceptor upon admission, or within a reasonable period of time.
3. Patients shall be admitted under the name of the attending physician/preceptor.
4. The supervising physician/preceptor shall see their admitted patients on a daily basis and write appropriate notes and orders in the patient's chart.
5. Residents may write admitting orders, daily orders, and daily progress notes; these do not have to be cosigned by the patient’s attending physician/preceptor.
6. Students may write record findings, and write order(s) on charts; any orders made by a medical student must be immediately countersigned or given verbal approval by the attending physician/preceptor to the RN (Charge nurse) before the order(s) can be implemented.
7. Residents may dictate admission history and physical notes, operative notes, and discharge summaries. All dictation, including admission H&Ps and discharge summaries, shall be countersigned by the attending physician/preceptor.
8. Residents/Students are eligible for specific privileges commensurate with their education and training within the limitations of those privileges held by the supervising physician/preceptor to whom they are assigned, and with direct supervision of the attending physician/preceptor, and as determined by the supervising department. Within these limitations, they may exercise independent judgment within their level of competency, providing that the supervising physician/preceptor shall have the ultimate responsibility for patient care.
9. Patients have the right to accept or refuse examination by residents/students.
10. Residents/Students shall wear identification badges which clearly identify them accordingly.
11. Residents/Students shall abide by the Hospital and Medical Staff Bylaws, Rules and Regulations and Policies and Procedures.
12. Residents/Students shall function in cooperation with the Southwest Memorial Hospital Quality Assurance and Improvement Plan and the Medical Staff Quality Assurance and Improvement Plan.
13. Residents/Students shall comply with all applicable requirements for all legal and regulatory agencies, including but not limited to, DNV, CMS and the Colorado Board of Medicine.
- ATTESTATION AND AGREEMENT -
I hereby declare that the above named medical resident will be functioning at Southwest Memorial Hospital under my direct supervision, will be limited to duties and functions specified above and as outlined in the Medical Staff Bylaws, Medical Staff Rules and Regulations, and Policies.
I assume full responsibility for the residents/students clinical activities by omission or commission.
I assume the responsibility of advising my patients the identity of the resident/student.
______
Supervising Physician/Preceptor Signature Date
I hereby apply to Southwest Memorial Hospital for appointment as a Medical Resident/Student. I have not requested privileges for which I am not qualified. I hereby certify that the information contained in this application is complete and accurate to the best of my knowledge, and acknowledge that any false information or misrepresentation may be grounds for denial of this application. I have read and understand the information included in the application packet.
ÿ I hereby certify that I am capable of performing the essential functions of a physician exercising the privileges for which I have applied.
ÿ I am in need of a reasonable accommodation, as follows:
______
Are you presently (within the last one hundred eighty days) using any illegal drug or controlled substance?
ÿ Yes ÿ No
______
Signature Date
- APPROVAL -
______
Doug Bagge, MD, Chief of Staff Date
______
Kent Helwig, CEO Date
Southwest Memorial Hospital
Medical Student Application
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