QUESTIONNAIRE FOR REVIEW, HIRE, TRANSFER OR PROMOTION OF
NON-PHYSICIAN PRACTITIONERS
Instructions:
Complete and submit with the HR requisition to hire, transfer or promote a Non-Physician Practitioner with one of the following professional job titles: Place an “X” to the left of the title.
_____ Nurse Practitioner, including Nurse Practitioner Associate
_____ Physician Assistant
_____ Genetic Counselor
_____ Certified Nurse Midwife
_____ Certified Registered Nurse Anesthetist
_____ Clinical Psychologist
_____ Audiologist
_____ Speech / Language Pathologist
_____ Nutritionist / Registered Dietician
Employer: ____ JHH ____ JHBMC ___JHUSOMSpecify department: ______
Status: ____ New Position ____ Replacement ____ Promotion ____ Transfer
Duties are: ____ Same as former employee ____ New duties
Duties are: ______Clinical ______Clinical Research ______Both
Description:
Specify whether the NPP’s role will be to:
______Practice independently under the supervision/collaboration of a physician(s)
______Practice directly / jointly with a physician(s)
______Function on behalf of the hospital
Will there be (check all that apply):
______Hospital billing of the NPP’s services – Level One only
______Hospital billing of the NPP’s services – Clinical Care Time (CCT)
_____ Pro fee billing for the NPP’s services
______Other (explain)
______Don’t know
List all locations where duties will be performed – campus affiliation, hospital, building, clinic, department, etc.
List the physician(s) name and department who will have oversight / be listed on the Collaboration or Delegation Agreement:
What is (are) the funding source(s) for this position?
Identify who will be responsible for the following:
Additional information (optional):
Completed by
Date:
Contact information:
FOR REVIEW TEAM ONLY
Requisition #:
Employee Name:
Anticipated start date:
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