October 4, 2018

DearPhysician:

Thankyou for your interest in applying for medical staff membership and clinical privileges at Minden Medical Center. Please find enclosed an application for medical staff membership, request for clinical privileges in yourspecialty, and ourhospitalbylaws, rules, and regulations.

Pleaseread all documents carefullybeforecompleting the application and request for clinical privileges. Our governingboarddeveloped the followinggeneral standards for applicants. Thesegeneral standards wereadopted to assist Minden Medical Center in achieving an appropriatelyhigh standard of patient care. Pleasebeawarethattheseare minimum standards. Uponreceipt of your completed application, our credentials committee will conduct a further review of your credentials before making a recommendation to our governing board. To qualify to apply to our medical staff you must:

  1. Be determined, on the basis of documented references, to adhere strictly to the ethics of your respective profession(s), to work cooperatively with others and to be willing to participate in the discharge of staff responsibilities;
  2. Comply and have complied with federal, state and local requirements, if any, for their medical practice, are not and have not been subject to any liability claims, challenges to licensure, or loss of Medical Staff membership or privileges which will adversely affect their services to the Hospital;
  3. Be currently licensed to practice in this state with no restrictions;
  4. Maintain professional liability insurance in the amount specified by Minden Medical Center’s governing board
  5. Have skills and training to fulfill a patient care need existing within the Hospital, and be able to adequately provide those services with the facilities and support services available at the Hospital; and
  6. Agree to comply with all hospital policies, rules, and regulations, and the hospital code of ethical conduct

If you meet all the above requirements, carefully review all the enclosed materials and complete the enclosed application and request for clinical privileges. Please return the documents to me 90 days prior to working at Minden Medical Center, along with full payment of the application processing fee (for Courtesy privileges ONLY: $275 for Initial Appointment), payable to Minden Medical Center. If you have any questions or require additional assistance, please do not hesitate to contact the medical staff office.

Sincerely,

Shannie Simon

Medical Staff Coordinator

Physician Credentials Application

Please complete ALL sections of application. «SEE CV» sections will be returned.

Date of Application:

LAST NAME: / FIRST: / MIDDLE: / MAIDEN:
Prof. Designation: M.D. / D.O. / D.P.M. / O.D. / D.D.S. / Sex:  Male  Female
Other Names Used: / Spouse Name:
Foreign Languages (spoken fluently by physician):
DOB: / SSN: / Citizenship: / Birth Place:
Specialty: / Subspecialties:
Home Mailing Address: / City:
State: / Zip:
Home Telephone #:
Home Fax #: / Cell Phone #:
Email Address:
Practice Name: / Department Name: (if applicable)
Primary Office Street Address: / City/State/Zip:
Office Phone #: / Office Fax #:
Office Manager: / Office Manager Email Address:
Secondary Office Street Address: / City:
State: / Zip:
Secondary Office Manager: / Secondary Office Phone #:
Secondary Office Fax #:
Branch: / Dates:
Rank: / Type of Discharge:
Are you able to safely perform all of the essential mental and physical functions related to the specific clinical privileges you are requesting? If not, on a separate sheet of paper, please describe the essential functions and state the reason why you may not be able to perform them? /  Yes  No
Does your physical or mental health affect your ability to practice medicine in such a way that others could be exposed to health or safety risks? If yes, please explain the nature of the health and safety risk on a separate sheet. /  Yes  No
Do you currently or have you ever engaged in the abuse of alcohol or the unlawful use of drugs, including the use of addictive prescription drugs not under the supervision of a licensed health care professional other than yourself? If yes, please explain on a separate sheet. /  Yes  No
Please list three (3) professional peers who have personal knowledge of your current clinical abilities, ethical character, and ability to work cooperatively with others. These should be individuals who will provide specific written comments on these matters upon request. The named individuals must have acquired the requisite knowledge through observation of your professional practice in the past three (3) years. These peers should be in the same specialty and/or the same field. None of your references should be relatives.
Name & Title of Peer: / Specialty:
Mailing Address: / Phone #:
Fax #/Email Address:
Name & Title of Peer: / Specialty:
Mailing Address: / Phone #:
Fax #/Email Address:
Name & Title of Peer: / Specialty:
Mailing Address: / Phone #:
Fax #/Email Address:
Name & Title of Peer: / Specialty:
Mailing Address: / Phone #:
Fax #/Email Address:

List All Medical Schools/Institutions Attended. Please explain any 6 month or greater gap in your training. Attach additional sheets if necessary.
Institution: / Degree Earned:
Dates Attended (Month/Year):
Mailing Address: / City:
State: / Zip:
If you are a Graduate of a Foreign Medical School, are you certified by the Education Council for Foreign Medical Graduates (ECFMG)? If yes, Please enclose a copy of your certificate with this application.  Yes  No
Institution: / Program Director/Department Chair:
Dates Attended (Month/Year):
Type of Internship (Rotating/Straight) – If Straight, Please list specialty:
Institution: / Program Director/Department Chair:
Dates Attended (Month/Year):
Type of Residency:
Institution: / Program Director/Department Chair:
Dates Attended (Month/Year):
Type of Fellowship/Other Explanation:
Please list in reverse chronological order (with current affiliation (s) first) all institutions where you have current affiliations (A) and have had previous hospital privileges (B). This includes hospital, surgery centers, institutions, corporations, military assignments, or government agencies. If an institution is no longer inexistence, please provide an alternative source of verification. If you do not have hospital privileges, please explain on a separate sheet. Please attach a current CV and explain any gaps in excess of six (6) months. Use “Hospital Affiliations” Addendum on page 12, if necessary.
Name and Mailing Address of Primary Admitting Hospital:
Telephone #: Fax#: / City:
State: / Zip:
Department/Status (active, provisional, courtesy, consulting, temporary, etc)
Any Past or Present Restrictions of Privileges?  Yes  No (IF YES EXPLAIN) / Appointment Dates:
LA State: / License #: / Expiration Date:
DEA # / Expiration Date:
CDS # / Expiration Date:
ECFMG#: / NPI #: / Medicaid #:
State: / License #: / Expiration Date:
State: / License #: / Expiration Date:
Type: / Expiration Date:
Type: / Expiration Date:
Type: / Expiration Date:
Type: / Expiration Date:
Are you certified by a recognized board of the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA)?  Yes  No; If not applicable to your profession/specialty, complete with N/A. Attach copy of certificate (s).
Name of Issuing Board: / Specialty: / Date Certified: / Recertified: / Expiration Date (if any):
Name of Present Carrier: / Policy #:
Complete Address: / Coverage Amounts: / Dates of Coverage:
Phone #: / Fax #
Name of Previous Carrier: / Policy #:
Complete Address: / Coverage Amounts: / Dates of Coverage:
Phone#: / Fax#:
If you answer “Yes,” please to question #1 or 2, then please use the enclosed Professional Liability Addendum on page 14.
1. Has your professional liability insurance ever been terminated, not renewed, restricted, or modified (e.g. reduced limits, restricted coverage, surcharged), or have you ever been denied professional liability insurance, or has any professional liability carrier provided you with written notice of any intent to deny, cancel, not renew, or limit your professional liability insurance or its coverage of any procedures? /  Yes  No
 Pending
2. Have you ever been a party to any lawsuit, including, but not limited to any professional liability claims or lawsuits
brought against you, including pending claims or lawsuits, dismissed or dropped claims or lawsuits, settlements or
final judgments? If yes, please provide the following items for each matter: (i) the parties to the lawsuit; (ii) the
date the lawsuit was filed; (iii) the court in which the lawsuit was filed; (iv) a description of the nature of the
lawsuit and the claims made by the parties; and (v) the outcome of the lawsuit and the date in which it was
resolved. Additionally, if the lawsuit involved medical malpractice, please complete the Addendum attached. /  Yes  No
 Pending

Name of Insurance Carrier:

Address of Carrier:

Fax Number:

Policy #

I, Dr. , am applying for appointment to the Medical Staff of Minden Medical Center and hereby authorize my Carrier to release to the Hospital all information regarding my Claims History, including but not limited to:

  1. Judgements entered
  2. Claims settled, and
  3. Cases and lawsuits pending

Please return this information to:

Minden Medical Center

Attn: Medical Staff Department (Shannie G.)

P.O. Box 5003

Minden, La 71058-5003

(318) 371-3239 fax

In authorizing the release of such information to the Hospital, I hereby release you from liability and indemnify you for acts performed in good faith and without malice in connection with supplying of this information needed for the processing of my application for appointment to the Medical Staff of Minden Medical Center. I also request that Minden Medical Center be added as a certificate holder and be mailed updated malpractice certificates as they are renewed.

Physician SignatureDate

1. Has your membership, participation, clinical privileges, or employment ever been denied, terminated, stipulated, restricted, refused, limited, suspended, revoked, or not renewed by any peer review organization, third party payer, clinic, hospital, medical staff, or any health-related agency or organization, or is there a review pending? /  Yes  No  Pending
2. Has your certificate or participation in any private, federal (i.e. Medicare, Medicaid, etc.) or state health insurance program ever been revoked or otherwise limited or restricted, or is any investigation or proceeding with respect to any such action presently underway? /  Yes  No  Pending
3. Are there any charges pending or are you currently charged with or have you ever been indicted or found guilty of a felony, misdemeanor (other than a minor traffic violation), or other offense involving fraud, misrepresentation, dishonesty or deceit? /  Yes  No  Pending
4. Have you ever been subject to investigation by a governmental entity that could result in sanctions or licensure adverse actions? /  Yes  No  Pending
5. Have you ever been reprimanded, censored, or otherwise disciplined by, or have you ever been subject to a corrective action agreement/plan with any licensing board, peer review organization, third party payer, clinic, hospital, medical staff, or any health-related agency or organization? /  Yes  No  Pending
6. Have your privileges at any healthcare entity ever been voluntarily or involuntarily suspended, restricted, diminished, revoked or not renewed, except for medical records? /  Yes  No  Pending
7. Have you ever resigned from a healthcare entity to avoid modification, suspension, or termination of privileges? /  Yes  No  Pending
8. Has your professional license or registration in any jurisdiction ever been terminated, stipulated, limited, restricted, conditioned, investigated, voluntarily or involuntarily limited, suspended or revoked, or not renewed by any licensing board of any health-related agency or organization, or are any currently held licenses pending investigation or being challenged? /  Yes  No  Pending
9. Have you ever been notified to appear before any licensing agency for a hearing or complaint of any nature? /  Yes  No  Pending
10. Has your federal or state narcotics registration certificate in any jurisdiction ever been voluntarily or involuntarily limited (stipulations), suspended, revoked, restricted, or surrendered, or is it currently being challenged? /  Yes  No  Pending
11. Do you know of any reason why you cannot perform the essential duties of the clinical privileges/functions which you are requesting with or without a reasonable accommodation according to acceptable standards of professional performance and without posing a direct threat to patients? /  Yes  No  Pending
12. Do you use illegal drugs or have you illegally used drugs in the past five years? /  Yes  No  Pending

I hereby affirm that the information submitted in this Section, Professional Practice Questions, and any addenda thereto is true, current, correct, and complete to the best of my knowledge and belief and is furnished in good faith. I understand that material, omissions or misrepresentations may result in denial of my reapplication or termination of my privileges/employment.

Signature: / Printed Name: / Date:

, MD

PHYSICIAN NAME

LICENSE NUMBER

MEDICARE

“Notice to Physicians: Medicare payment to hospitals is based in part on each patient’s principal and secondary diagnoses and the major procedures performed on the patient, as attested to by the patient’s attending physician by virtue of his or her signature in the medical record. Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal Funds, maybe subject to fine, imprisonment, or civil penalty under applicable Federal Laws.”

I, __ MD, certify that I have received the above statement.

Signature: / Printed Name: / Date:

CHAMPUS

“Notice to Physicians: Champus payment to hospitals is based in part on each patient’s principal and secondary diagnoses and the major procedures performed on the patient, as attested to by the patient’s attending physician by virtue of his or her signature in the medical record. Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal Funds, maybe subject to fine, imprisonment, or civil penalty under applicable Federal Laws.”

I, _ , MD, certify that I have received the above statement.

Signature: / Printed Name: / Date:

NOTE: THIS FORM IS ONLY FOR APPLICANTS APPLYING FOR ACTIVE AND COURTESY PRIVILEGES

Each licensing board has specific requirements governing the amount of CME credits (20.0) needed each year to maintain current licensure. Please list below the courses completed, and the location, date and the number of hours of CME credits you have obtained during the past 2 (two) years. These courses must be specialty specific. If necessary, use an additional sheet, andplease send a copy of your listing of courses or certificates. If just out of Residency or Fellowship, please indicate that below then sign and date the form.

Course Taken / Location / Date / Number of
CME Hours

100% of CMEs is required. Please indicate on the line below.

During the past two years, ______% of my continuing medical educational activities was related to the privileges requested. I hereby certify that within the past two years I have completed at least the minimum number of hours of continuing education credits (20 CMEs per year) required by the board through which I am licensed, and have participated in all performance improvement activities as specified by Minden Medical Center. If audited, I will be able to provide documentation of the seminars or courses attended. I recognize that failure to produce documentation upon request will jeopardize my membership on the medical staff.

Signature: / Printed Name: / Date:

Authority to Release: I hereby apply for Medical Staff appointment to MINDEN MEDICAL CENTER as requested in this application and, whether or not my application is accepted; I acknowledge, consent and agree as follows:

As an applicant for appointment, I have the burden for producing adequate information for proper evaluation of my qualifications. I also agree to update the Hospital with current information regarding all questions contained in this application as such information becomes available and any additional information as may be requested by the Hospital or its authorized representatives. Failure to produce any such information will prevent my application for appointment from being evaluated and acted upon. I hereby signify my willingness to appear for the interview, if requested, in regard to my application.

Information given in or attached to this application is accurate and complete to the best of my knowledge. I fully understand and agree that as a condition to making this application, any misrepresentations or misstatement in, or omission from it, whether intentional or not, shall constitute cause for automatic and immediate rejection of this application, resulting in denial of appointment and clinical privileges. I further acknowledge that if it has been reasonably determined that I have made a misstatement, misrepresentation, or omission in connection with an application that is discovered after appointment and/or the granting of clinical privileges, I shall be deemed to have immediately relinquished my appointment and clinical privileges.

(1)I extend immunity to, and release from any and all liability, the Hospital, its authorized representatives and any third parties, as defined in subsection (3) below, for any acts, communications, recommendations or disclosures performed without intentional fraud or malice involving me; performed, made, requested or received by this Hospital and its authorized representatives to, from or by any third party, including otherwise privileged or confidential information, relating, but not limited to, the following:

(a)applications for appointment or clinical privileges, including temporary privileges;

(b)periodic reappraisals;

(c)proceedings for suspension or reduction of clinical privileges or for denial or revocation of

appointment, or any other disciplinary action;

(d)summary suspension;

(e)hearings and appellate reviews;

(f)medical care evaluations;

(g)utilization reviews;

(h)any other Hospital, Medical Staff, department, service or committee activities;

(i)inquiries concerning my professional qualifications, credentials, clinical competence, character,

mental or emotional stability, physical condition, ethics or behavior; and

(k)any other matter that might directly or indirectly impact or reflect on my competence, on patient

care or on the orderly operation of this or Hospital.

(2)I specifically authorize the Hospital and its authorized representatives to consult with any third party who may have information, including otherwise privileged or confidential information, bearing on my professional qualifications, credentials, clinical competence, character, mental or emotional stability, physical condition, ethics, behavior or other matter bearing on my satisfaction of the criteria for continued appointment to the Medical Staff, as well as to inspect or obtain any all communications, reports, records, statements, documents, recommendations and/or disclosure of said third parties relating to such questions. I also specifically authorize said third parties to release said information to the Hospital and its authorized representatives upon request.