HSM Form # 3
Application for Medical Staff Appointment and Clinical Privileges
Name: «ProviderDemographics.ProviderFullName_FN», «ProviderDemographics.Title»
Date of Application: «ProviderDemographics.CurrentDate»
Specialty: «ProviderDemographics.Specialty»
Instructions:
1. All information must be typed or printed.
2. If more space is needed, attach additional sheets and make reference to the questions being answered.
3. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.
4. If not previously provided, please attach copies of the following documents to this application:
(a) Current license(s) to practice your profession;
(b) Current DEA registration and state controlled substance license (if applicable);
(c) Current certificate of professional liability insurance coverage from insurance carrier;
(d) ECFMG certificate (if foreign medical graduate);
(e) Evidence of Board certification;
(f) Government-issued photo identification (passport, driver’s license); and
(g) Current curriculum vitae.
5. Please indicate any clinical privileges that you are requesting outside of the core privileges in your specialty by completing the attached clinical privilege request form.
6. Please attach evidence of your current clinical competence/activity to support your request for clinical privileges, as follows:
(a) If you just completed your training and have not held medical staff membership at any hospital, please attach a copy of your residency log (and fellowship log if applicable).
(b) If you completed your residency and/or fellowship within the past five (5) years, please attach a copy of your residency log (and fellowship log, if applicable) and your quality profile (or similar documentation) from the hospital(s) where you have practiced, showing your clinical activity, including numbers of procedures performed, morbidity, mortality, infection rates and other complications.
(c) If you completed your residency and/or fellowship training more than five (5) years ago, please attach your quality profile (or similar documentation) from the hospital(s) where you have practiced in the past twenty-four (24) months, showing your clinical activity, including numbers of procedures performed, morbidity, mortality, infection rates and other complications.
7. Submit the completed, signed application form to the Medical Staff Office, along with all of the requested documentation and supplemental forms, any required application processing fees, and the completed clinical privileges request form.
I. GENERAL INFORMATION
Name:
Home Address:
Home Telephone Number:
Birth Date ______Social Security # ______UPIN #
Medicaid Provider # ______Medicare Provider #
Workers' Compensation Provider #
Visa Status (if not a U.S. citizen):
Driver’s License #: ______State:
E-Mail Address:
II. PRIVATE PRACTICE INFORMATION
Name of Practice:
Practice Mode: ___ Solo ___ Group ___ Other:
Others with whom you are associated in practice and nature of association:
Beeper Number: ______After Hours Phone:
Primary Office Address:
City: ______State: ______Zip:
Telephone Number: ______Fax Number:
Second Office Address:
City: ______State: ______Zip:
Telephone Number: ______Fax Number:
Please list the name of at least one medical staff member with appropriate clinical privileges who has agreed to provide alternate coverage for your hospitalized patients in the event of your unavailability:
III. PROFESSIONAL INFORMATION
Please answer each of the following questions. If the answer to any question is "yes," please provide a full explanation with details on a separate sheet and attach.
1. Has your DEA registration or any state controlled substance license ever been relinquished, limited, denied, suspended, or revoked, or have any conditions been placed on them, whether voluntarily or involuntarily?
Yes ___ No ___
2. Is your DEA certificate or any state controlled substance license currently being investigated or challenged?
Yes ___ No ___
3. Have you ever been suspended, sanctioned, excluded, or otherwise precluded from participating in Medicare, Medicaid, or any other federal, state or private health insurance program?
Yes ___ No ___
4. Have you ever been the subject of an investigation by any private, federal, or state agency concerning your participation in any private, federal, or state health insurance program?
Yes ___ No ___
5. Have you ever been arrested for or charged with any crime?
Yes ___ No ___
6. Have you ever been convicted of, or pled guilty or no contest to, any felony, or any misdemeanor relating to the practice of your profession, other health care-related matters, third-party reimbursement, violence, or controlled substances violations?
Yes ___ No ___
IV. EDUCATION DATA
A. SCHOOLS / DEGREE / DATE OF GRADUATIONUndergraduate College or University
______
______
______/ ______
______
______/ ______
______
______
Medical or Dental School
______
______
______/ ______
______
______/ ______
______
______
B. INTERNSHIPS
List every internship begun or completed. If more than one internship was begun or completed, please supply the same information on a separate sheet and attach.
Dates: ______to
(month/year)(month/year)
Institution:
Address:
Type of Internship:
Program Director:
Was the program successfully completed? Yes ___ No ___
C. RESIDENCIES
List every residency begun or completed. If more than two residencies were begun or completed, please supply the same information on a separate sheet and attach.
Dates: ______to
(month/year)(month/year)
Institution:
Address: _
Department Chief or Program Director:
Specialty:
Was the program successfully completed? Yes ___ No ___
Dates: ______to
(month/year)(month/year)
Institution:
Address:
Department Chief or Program Director:
Specialty:
Was the program successfully completed? Yes ___ No ___
D. FELLOWSHIPS
List every fellowship begun or completed. If more than one fellowship was begun or completed, please supply the same information on a separate sheet and attach.
Dates: ______to
(month/year)(month/year)
Institution:
Address:
Department Chief or Program Director:
Type of Fellowship:
Was the program successfully completed? Yes ___ No ___
E. TEACHING APPOINTMENTS
List every teaching appointment begun or completed. If more than one teaching appointment was begun or completed, please supply the same information on a separate sheet and attach.
Dates: ______to
(month/year)(month/year)
Institution:
Address:
Department Chief or Program Director:
Type of Appointment:
F. CONTINUING MEDICAL/PROFESSIONAL EDUCATION (during past three years)
Dates: ______to
Institution:
Address:
Course Title:
Dates: ______to
Institution:
Address:
Course Title:
Dates: ______to
Institution:
Address:
Course Title:
Dates: ______to
Institution:
Address:
Course Title:
V. INSTITUTIONAL AFFILIATIONS
List in chronological order all institutional affiliations since completion of your postgraduate education. This includes all hospitals, corporations, military assignments, or government agencies. Complete addresses must be included. If more space is needed, please attach an additional sheet. This information may be supplemented by, but not replaced by, attaching a copy of your curriculum vitae.
Dates: ______to
(month/year)(month/year)
Institution:
Address:
Department Chief:
Staff Category:
Dates: ______to
(month/year)(month/year)
Institution:
Address:
Department Chief:
Staff Category:
Dates: ______to
(month/year)(month/year)
Institution:
Address:
Department Chief:
Staff Category:
VI. EMPLOYMENT/WORK HISTORY
List in chronological order all employers since completion of your postgraduate education. This includes all medical groups, hospitals, corporations and government agencies (unless already listed in Section V above). Complete addresses must be included. If more space is needed, please attach an additional sheet. This information may be supplemented by, but not replaced by, attaching a copy of your curriculum vitae.
Dates: ______to
(month/year)(month/year)
Employer:
Address:
Supervisor/Managing Partner:
Dates: ______to
(month/year)(month/year)
Employer:
Address:
Supervisor/Managing Partner:
Dates: ______to
(month/year)(month/year)
Employer:
Address: _
Supervisor/Managing Partner:
If the answer to any of the following questions is "yes," please provide a full explanation with details on a separate sheet and attach.
1. Has your employment, medical staff appointment or clinical privileges, or status as a participating provider in a managed care organization ever been relinquished, withdrawn, suspended, reduced, revoked, denied, investigated, challenged, not renewed, or subject to probationary or other conditions at any hospital, health care facility, or managed care organization, whether voluntarily or involuntarily?
Yes ___ No ___
2. Have you ever withdrawn your application for appointment, reappointment or clinical privileges at any hospital or health care facility, or for participating provider status in a managed care organization, or resigned before a decision was made by a governing board?
Yes ___ No ___
3. Are there presently any proceedings or investigations taking place at any hospital, health care facility, or managed care organization relating to your clinical competence or professional conduct?
Yes ___ No ___
4. Have you ever been the subject of focused individual monitoring relating to your clinical competence or professional conduct at any hospital, health care facility, or managed care organization?
Yes ___ No ___
VII. ABILITY TO EXERCISE PRIVILEGES
1. Are you able to safely and competently exercise the clinical privileges requested and perform the duties and responsibilities of appointment, including, but not limited to, emergency service coverage and committee service?
Yes ___ No ___
2. Are you presently using any illegal drugs or any other substance in an illegal manner that would impair your ability to practice safely?
Yes ___ No ___
(Note: the Health Status Confirmation Form must also be completed and reviewed prior to final Board action on your application.)
VIII. Licensure and PROFESSIONAL ASSOCIATIONS
A. Licensure
Please include information for each state in which you currently hold or have held an active license to practice your profession.
State / License Number / Expiration Date______
______
/ ______
______ / ______
______
If the answer to any of the following questions is "yes," please provide a full explanation with details on a separate sheet and attach.
1. Have any investigations or disciplinary actions ever been initiated by any state licensure agency or are there any currently pending?
Yes ___ No ___
2. Has your license to practice in any state ever been relinquished, suspended, modified, restricted, denied, challenged, or terminated, whether voluntarily or involuntarily?
Yes ___ No ___
3. Have you ever been asked to surrender your license in any state?
Yes ___ No ___
4. Have you ever been reprimanded or otherwise sanctioned by, or had conditions placed on your license by, any licensure agency?
Yes ___ No ___
B. Membership in Professional Societies (local, state, or national)
Name & Address / DatesFrom /
To
______
______
______
/ ______
______
______ / ______
______
______
Have you ever been denied membership or renewal thereof, or been subject to disciplinary proceedings, in any professional organization? Yes ___ No ___
If "yes," please provide a full explanation with details on a separate sheet and attach.
C. Board Certification
1. Names of specialty Boards by which you are certified:
Specialty Board ______Date ______
Specialty Board ______Date ______
2. Have you ever failed to pass a Board certification examination? Yes ___ No ___
If "yes," please provide a full explanation with details on a separate sheet and attach.
3. If not certified, have you applied for the certification examination? Yes ___ No ___
If "no," do you intend to apply for the certification examination? Yes ___ No ___
4. Have you been accepted to take the certification examination? Yes ___ No ___
If "yes," what dates are you scheduled to take the certification examination?
______
5. Date(s) of next required recertification examination (if applicable): ______
IX. PROFESSIONAL LIABILITY DATA
A. Insurance
Present Carrier:
Address:
Level of Coverage:
Policy Number: ______/ Effective Dates: ______(month/day/year)
List Carriers for the past 10 years:
______(Name) / ______
(Address) / ______
(Coverage Period)
______
(Name) / ______
(Address) / ______
(Coverage Period)
1. Do you have "tail coverage"? Yes ___ No ___
2. Has your professional liability insurance coverage ever been terminated by action of the insurance company? Yes ___ No ___
3. Have you ever been denied professional liability insurance coverage?
Yes ___ No ___
4. If the answer to question 2 or 3 above is "yes," state when and by what company:
______
5. Has any professional liability insurance carrier ever excluded any specific procedures from your coverage? Yes ___ No ___
If the answer is "yes," please list the procedures that have been excluded and provide a full explanation on a separate sheet, including the name of the carrier, the date, and specific information concerning any limitation.
6. Has any insurance company ever imposed a surcharge or additional premium because of your claims history? Yes ___ No ___
B. Legal Actions
1. Have any professional liability suits ever been filed against you?* Yes ___ No ___
2. Are any professional liability suits against you presently pending?* Yes ___ No ___
3. Have any judgments been made against you, or have there been any settlements involving you, in professional liability cases?* Yes ___ No ___
If the answer to any of the above questions is "yes," please provide a full explanation with details on every matter on the attached Description of Professional Liability Suits/Claims form. The explanation must include the name of the court in which the suit was filed, the caption and docket number of the case, the name and address of the attorney defending you, and a description of the case and the status or disposition.
* Please include suits in which a judgment or settlement was made against a professional corporation of which you are/were a member, shareholder, or employee in any matter in which you were involved in the patient's care.
X. REFERENCES
List at least three professional references, not including relatives, current partners or associates in practice, who have had recent extensive experience in observing and working with you. References will be evaluated according to the extent of their direct clinical observation of your work and other knowledge of you. At least one reference must practice in your clinical specialty. Please provide current, complete addresses.
1. Name:
Address:
City: ______State: ______Zip:
Telephone:
2. Name:
Address:
City: ______State: ______Zip:
Telephone:
3. Name:
Address:
City: ______State: ______Zip:
Telephone:
XI. CONDITIONS OF APPLICATION, RELEASE AND IMMUNITY
A. Conditions of Application
In return for my application being considered and processed, I agree to be legally bound by the following terms and conditions:
1. I understand that it is my responsibility to produce adequate information so that my application can be properly evaluated. In addition to the information provided in this application, I also agree to provide the Hospital with any additional information that the Hospital or one of its authorized representatives may request. MY FAILURE TO PROVIDE ANY REQUESTED INFORMATION WILL CAUSE MY APPLICATION TO BE INCOMPLETE AND WILL PREVENT IT FROM BEING PROCESSED.