Helena SurgiCenter, LLC

ALLIED HEALTH PROFESSIONAL STUDENT APPLICATION

IDENTIFYING INFORMATION

Last NameFirstMiddle / Social Security Number
Office Address / City/State/Zip / Office Telephone
Home Address / City/State/Zip / Home Telephone

EDUCATION

College or University / City/State / Date of Graduation / Degree
Institution of Special Training

LICENSING

State License Number / Expiration Date

PROFESSIONAL LIABILITY INSURANCE (Attach a copy of the Insurance Binder.)

Current Carrier Agent / Limits of Coverage / Effective Dates

IN THE PAST THREE YEARS:

1. / Have your privileges at a hospital or other health care facility been denied, limited, suspended, non-renewed or revoked? /  Yes  No
2. / Have you been involved in proceedings brought by a hospital or other health care facility to deny, limit, suspend, non-renew or revoke your privileges. /  Yes  No
3. / Has your license been limited, suspended or revoked in any state? /  Yes  No
4. / Have you been placed on probation by any licensing board? /  Yes  No
5. / Have you been notified to respond to or appear before any licensing or regulatory agency on a complaint of any nature, including, but not limited to, unprofessional or unethical conduct? /  Yes  No
6. / Have you ever been sued for medical malpractice?
If yes, are there any claims pending? /  Yes  No
 Yes  No
7. / Have you been charged with, or convicted of a felony or misdemeanor, other than traffic violations? /  Yes  No
8. / Have you been treated or hospitalized for any mental or emotional disorders? /  Yes  No
9. / Have you been treated or hospitalized for use of any of the following:
Alcohol
Narcotics
Central nervous system stimulants or depressants /  Yes  No
 Yes  No
Yes  No
If you answered YES to any of these questions, full details are required in writing.
To the best of my knowledge, the above statements are the truth and
I have not knowingly withheld any information. / Signature

In making this application for approval as An Allied Health Professional Student, I agree to abide by Facility policies and procedures. I fully understand that my authorized activities will be strictly delineated by the Medical Staff and by my supervising physician. I will promptly notify the HSC Administration and my supervising physician of any change in my status as it has been reported on this form.

In completing this application, I fully realize that I am not applying for membership in the Medical Staff of this facility and that I will not be entitled to the legal right of due process afforded under the Medical Staff Bylaws. Furthermore, I understand that my authorized activities may be terminated or suspended at any time at the discretion of the supervising physician, the Medical Director and/or the Governing Body.

Applicant's Signature / Date
STATEMENT OF RESPONSIBILITY FOR ALLIED HEALTH PROFESSIONAL
I hereby agree to accept total responsibility of the Allied Health Professional while supervising. I also attest to the fact that an adequate investigation of the Affiliate's qualifications and character has been performed and that the individual, in my opinion, is capable of performing requested privileges.
Supervising Physician's Signature / Date

For Administrative Purposes Only

Allied Health Professional:
 Recommended  Not Recommended
______
Quality Management Committee ChairpersonDate / Allied Health Professional:
 Approved  Not Approved  Deferred
______
Governing Body ChairpersonDate

MS-F12 (1 of 3)