UVAMedicalCenter,
UVA Transitional CareHospital
UVAHealthSouthRehabilitationHospital
ALLIED HEALTH PROFESSIONAL PRIVILEGING
APPLICATION
I hereby make application for Credentialing in the Department of and submit the following information concerning my education and practice, professional character, and ethics. I understand that such information will be used in the evaluation of my request for clinical privileges and I am under a continuing obligation to update my information including, but not limited to: a) any reduction in the scope, extent or duration of clinical privileges or activities, b) any planned expansion in the scope, extent or application of clinical privileges or activities, c) any planned break in using clinical privileges for reasons such as leave of absence, sabbatical, etc. or any of the reasons listed under "Credentialing Questions" in this application. Information shall be updated, as required, by written notification to the Clinical Staff Office.
Please select the facility/facilities for which you wish to apply. (The credentialing process is centralized through the UVA Medical Center Credentialing and Privileging Process for your convenience and to expedite patient care)
UVA Medical Center
UVA Transitional Care Hospital
UVA Health South Rehabilitation Hospital
Personal Data
Social Security #Date of Birth City/State of Birth
Name in Full
Last NameFirst NameMiddleSuffixMaiden Name
Home Address Interoffice Box #
Address
Home Phone
City State Zip
Primary Employer (check one):☐ UPG☐ Med Ctr ☐NsgSchool ☐Other
Clinician Type(NP, PA, etc)
Work Location: Work Phone
Education & Post-Graduate Training
Name of Institution Location Dates Degree Major/Program
Colleges/Univ Attended
Grad/Prof
School/Prog
Professional Experience (Starting with the most recent, list all positions for the last ten years. Attach additional pages as necessary.)
Title
Employer/Practice Name From To
Address Phone#
Title
Employer/Practice Name From To
Address Phone#
Title
Employer/Practice Name From To
Address Phone#
Title
Employer/Practice Name From To
Address Phone#
LicensureLicense #StateExpiration DateLicense TypeLicensing Board
DEAFederal Government
Nurse Practitioners: Do you have an Authorization to Prescribe license in Virginia? ☐Yes ☐ No (check one)
If no, do you plan to apply? ☐Yes ☐No If yes, when?
Certification
Name of BoardCertified(y/n)Certification #Date CertifiedRecertification Date
References (Two people with knowledge of your professional competence and character. New graduates, please provide names of preceptors.)
Name Title
Institution Telephone
Address City, State, Zip
Name Title
Institution Telephone
Address City, State, Zip
Medicare/Medicaid
Have you been or are you currently enrolled as a Medicare Provider (including as a Locum Tenen, or through part-time work)?
yes ☐ no ☐ If yes, please provide NPI Number
Professional Liability Coverage (Beginning with current insurer and dating back a full ten years)
Insurance CompanyEffective Dates of Coverage
Full Address Limits of Coverage
Policy NumberTelephone Number
Type of Coverage Claims Made? Yes☐No☐Occurrence? Yes ☐ No ☐
If Claims Made, who provides your tail coverage?
Insurance CompanyEffective Dates of Coverage
Full Address Limits of Coverage
Policy NumberTelephone Number
Type of Coverage Claims Made? Yes☐No☐Occurrence? Yes ☐ No ☐
If Claims Made, who provides your tail coverage?
Insurance CompanyEffective Dates of Coverage
Full Address Limits of Coverage
Policy NumberTelephone Number
Type of Coverage Claims Made? Yes☐No☐Occurrence? Yes ☐ No ☐
If Claims Made, who provides your tail coverage?
Credentialing Questions(IF YOU ANSWER “YES” TO ANY OF THE QUESTIONS, YOU MUST ATTACH DETAILS IN WRITING,
INCLUDING DATE, PLACE, REASON, AND DISPOSITION OF THE MATTER, AS WELL AS OTHER,
RELEVANT INFORMATION)
Have you ever had a malpractice claim filed against you?
(If yes, complete attached claims history sheet for each claim)
Has a lawsuit ever been settled on your behalf?
Has a verdict ever been rendered against you in a malpractice lawsuit?
Have you ever been denied professional liability coverage?
Have you ever been denied clinical privileges at another health care facility or managed care entity ever revoked,
suspended, limited and/or reduced?
Have you ever been denied clinical privileges or had them revoked, suspended, limited and/or reduced?
Have you ever been reprimanded, suspended or terminated by an employer for reasons related to your clinical judgment?
Has any state or federal licensing entity limited, revoked, suspended, or denied a certificate or license or taken
other disciplinary action against you
Has any state licensing entity initiated an investigation or formal action against your professional licensure status?
Have you ever voluntarily or involuntarily relinquished your professional license, DEA registration, or certification, or have you
ever voluntarily or involuntarily relinquished or reduced your clinical privileges on any professional staff?
Have you ever been suspended, excluded or otherwise sanctioned by Medicaid, Medicare or any other
federal program
Have you ever been convicted of a violation of local, state or federal statute, regulation or entered into a plea agreement
relating to a felony or misdemeanor? (Exclude traffic violations, except convictions for driving under the influence and
reckless driving)?
Do you suffer from any physical, mental, or emotional problems which affect, or are likely to affect, your ability to
perform your duties as an allied health professional?
Do you take medication or drugs (including alcohol or any form of drug, legal or illegal) that affect, or are
likely to affect your ability to perform your duties as an allied health professional?
Do you, or any member of your immediate family, have an ownership interest in any health care organization
(not including an ownership in a mutual fund)?
I hereby understand that should the answer to any of the confidential questions listed on this application change, I understand that I am under a continuing obligation to immediately notify the Credentials Committee of such changes in writing so long as I remain credentialed as an Allied Health Professional.
I hereby make application for clinical privileges with the University of Virginia Health System. I understand and agree that as an applicant for Allied Health Professional membership, I have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubts about such qualifications. I understand that any mis-statements in or omissions from this application constitute cause for denial, modification, suspension, or revocation of my appointment and/or clinical privileges. I certify that to the best of my knowledge and belief all information provided in this application is true, correct and complete.
Further, should reasonable question exist regarding my physical or mental ability to perform the clinical privileges requested and/or granted, I agree to undergo a mental or physical examination, if requested. Should the examination provide evidence of mental or physical impairment, I understand it is my burden to show reasonable evidence that the impairment does not interfere with my professional competence.
In making this application, I understand and agree, that in applying for clinical privileges in the University of Virginia Health System, I may also be applying to be granted clinical privileges for any University of Virginia entity or affiliate entity or third party contractor of any part of the University of Virginia, including the Medical Center, Regional Primary Care Practices, and affiliated foundations, such as the University of Virginia Physicians Group,UVA Transitional Care Hospital and UVA- HealthSouth Rehabilitation Hospital. I agree to release of my credentialing and privileging information by the Credentials Committee and its staff office for such purposes where required by contract with one of these entities and/or where requested or endorsed by the Health System in accordance with established policy. My credentialing and privileging information may be released only for the purpose of my being credentialed by such third party contractors under an institutional contract or for credentialing by an arm of the University unless otherwise explicitly authorized by me in writing. All reasonable effort will be made to maintain this information as confidential and to preserve any legal privilege afforded the information.
If I am granted clinical privileges, I agree, as an Allied Health Professional of the University of Virginia Health System, to abide by the rules, regulations, and standing policies of the Health System and of the entities or affiliate entities, including the Medical Center, Regional Primary Care Practices, and affiliated foundations, such as the University of Virginia Physicians Group,UVA Transitional Hospital and UVA-HealthSouth Rehabilitation Hospital. Further, I pledge to maintain an ethical practice, abiding by the ethical principles set forth by the American Medical Association, with my patient’s interest at the center of the care I render. I also understand that anytime I take on new responsibilities I must update my clinical privileges. Specifically, anytime I plan to undertake a procedure or therapy for which I have received additional education and/or training, I must first request approval from the Credentials Committee, including any instance where new equipment will be used for an existing therapy or procedure and/or for a new therapy or procedure.
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Applicant SignatureDate
UVA Medical Center,
UVA Transitional Care Hospital &
UVA Health South Rehabilitation Hospital
ATTESTATION STATEMENT
I hereby attest that all information provided on this application for clinical privileges at the Medical Center and/or the University of Virginia Physicians Group,UVA Transitional Care Hospital and UVA HealthSouth Rehabilitation Hospital is true, correct, and complete. I understand and agree that I have the burden of producing adequate documentation of my competence, qualifications, character and such other qualifications as are relevant, and for resolving any doubts about such qualifications. Further, I understand that any mis-statements or omissions from this application constitute cause for denial, modification, suspension, or termination of my faculty appointment and/or clinical privileges.
I hereby understand that should the answer to any of the confidential questions listed on the Allied Health Professional Privileging Application change, I understand that I am under a continuing obligation to immediately notify the Credentials Committee of such changes in writing to retain clinical privileges with the University of Virginia Health System.
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Applicant SignatureDate
UVA Medical Center,
UVA Transitional Care Hospital &
UVA Health South Rehabilitation Hospital
CLAIMS HISTORY SHEET
If you answered “yes” to question #1 on page 3 of the AHP Credentialing/Privileging Application, please complete a claims history sheet for each claim in which you have been involved. Make additional copies of this form as needed.
Claimant:
Date of Incident: Date Claim Made:
Name of all Defendants, Persons or Entities against whom claim was made:
City, County and State of Suit:
Name and Address of Defense Attorney:
Settlement Amount (if any): Verdict Amount: Date Case Closed:
Current Status of Claim (indicate insurance company reserve if case is not closed):
Name of Involved Insurance Company:
Detailed Description of Claim:
UVA Medical Center,
UVA Transitional Care Hospital &
UVA Health South Rehabilitation Hospital
RELEASE OF INFORMATION
By applying for privileges to practice in the University of Virginia Health System, I hereby signify my willingness to authorize the hospital, its Credentials Committee and their representatives to consult with administrators and members of professional staff of other hospitals or institutions with which I have been associated and with others, including past and present malpractice carriers, who may have information bearing on my professional competence, character, and ethical qualifications. I hereby further consent to the inspection by the hospital, its Clinical Staff and its representatives of all records and documents, including medical records, at other hospitals, that may be material to an evaluation of my professional qualifications and competence to carry out the clinical privileges requested, as well as my moral and ethical qualifications and staff membership.
I understand and agree that I have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications, and for resolving any doubts about such qualifications.
I hereby release from liability all representatives of the Health System and its Clinical Staff for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and I hereby release from any liability all individuals and organizations who provide information to the Health System, or its Clinical Staff, in good faith and without malice concerning my professional competence, ethics, character, and other qualifications for staff appointment and clinical privileges, and I HEREBY CONSENT TO THE RELEASE OF SUCH INFORMATION.
It is my understanding that a copy of this Release of Information will be provided to each individual, hospital or organization where information on my credentials is sought in writing, and that the original of this document shall be kept on file in the Clinical Staff Office of the University of Virginia Health System.
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SignatureDate
Printed Name
Revised 09/11/2014Allied Health Professional Credentialing Application Pg. 1