HEALTHCARE ENTITIES INFORMATION FORM

Name of Facility:Memorial Hermann - KatyHospital

Address:23900 Katy Freeway.

Katy, Texas77494

Telephone Numbers:(281) 644-7000(Main Number)

(281) 644-7276(Medical Staff Office)

(713) 448-6464 (Centralized Credentialing Office)

Type of Entity:Not for profit

Services Offered:General Medical and Acute Care

Approximate size of Medical Staff: 475

Administrator:Scott Barbe, CEO

Number of Beds:127

Fees:(Initial Appointment)$250.00 non-refundable

(Reapplication)$250.00 non-refundable

(Allied Health Practitioner)N/A

Mandatory Orientation:Orientation held the 4th Thursday of Every Month

PRELIMINARY QUALIFICATIONS FOR MEMBERSHIP

Only applications which meet all of the criteria will be processed.

Please review the following and make note of the requirements for hospital privileges.

PLEASE NOTE: Due to exclusive contracts being in place at Memorial Hermann – KatyHospital, applications for Anesthesiology, Emergency Medicine, Pathology, and Radiology privileges will not be accepted for membership, unless applicant is affiliated with the contracting organization.

  • Board Certification in the clinical specialty in which privileges are being requested, recognized by the American Board of Medical Specialties, the American Osteopathic Association, the American Board of Oral and Maxillofacial Surgery, the American Board of Podiatric Surgery, or the American Board of Podiatric Orthopedics; OR completion of a residency program approved by the Accreditation Council for Graduate Medical Education within the immediately preceding five year period, Board eligibility in the clinical specialty in which privileges are being requested and Board certification within five years of completing residency or fellowship training program.

I understand that I must have sufficient patient activity to continue Medical Staff membership.

I will be required to submit the name(s) of the Practitioner(s) who agree to provide clinical specialty coverage in the event that I am absent from the hospital.

Emergency Room call coverage and the treatment of all E.R. patients, regardless of their ability to pay, may be required as determined by the department/section.

I agree to abide by the Bylaws and Rules of the Medical Staff/Credentialing Manual/Procedural Review Plan.

I will complete the physician orientation as required by the Medical Executive Committee. Orientation modules will include but are not limited to: Core Measures, Care Management, Patient Safety, E-ordering, Patient Satisfaction, Hospital Operations and Clinical Integration. Orientation is offered monthly and information of available dates and times may be obtained from Medical Staff Services at 281-644-7071 or Physician Relations at 281-644-7275.

MEMORIAL Hermann - KATYhospital

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Podiatrists: All Podiatric applicants to the Medical Staff must document the following:

Successful completion of a one year approved post-graduate Podiatric residency program;Board eligibility or certification with either the American Board of Podiatric Surgery or the American Board of Podiatric Orthopedics;

Podiatrists wishing to use the operating room facilities must have Board admissibility granted by the American Board of Podiatric Surgery and must obtain certification by that Board within four years of completion of their residency requirement;

Applications for operating room privileges must include a copy of the list of surgical cases presented to and approved by the Board;

If certification is not obtained within four years, surgical privileges will automatically be revoked.

Dentists: Dentists making application to the Dentistry Section must document the following:

Board certified in a specialty recognized by the American Dental Association (ADA) OR satisfactory completion of a specialty residency program approved by the ADA.

General Dentists: completion of an internship or residency in general dentistry approved by the ADA which includes training in hospital dental care; successful completion of postgraduate training in hospital dental care at an institution approved by the ADA and service as an assistant surgeon in the management of at least 15 cases; demonstration of experience in hospital dental care with documentation of being dentist of record on at least 25 cases.

I certify that I have read and fully understand this document and meet the requirements for medical staff membership at Memorial Hermann – KatyHospital. I will provide the necessary documentation requested and understand that failure to provide evidence of the above during the application process will result in my application being placed in the inactive files.

Please forward the application for privileges as well as all documentation pertinent to those facilities to which I wish to apply.

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