Application for Professional Appointment

Please choose one:

Physician  DentistPsychologist

 Nurse Practitioner/Physician Assistant Dental Hygienist Social Worker

Instructions for Completing:

  1. All information should be typed or legibly printed.
  2. If more space is needed, attach additional sheets and make reference to the question being asked.
  3. Please attach copies of the following documents to this application:

a)Curriculum Vitae

b)Current licenses to practice specialty;

c)Current DEA registration certificate;

d)ECFMG certificate (if foreign medical graduate);

e)Evidence of board or specialty certification (if applicable); and

f)Copy of degree(s).

Mail completed application with attachments to:

Attn: Clinical Operations Officer

North Country Family Health Center, Inc.

238 Arsenal Street

Watertown, New York 13601

APPLICANT INFORMATION

Name

Date of Birth Social Security Number

Address

Cell Phone Home Phone

Place of BirthCitizenship

Emergency Contact Relationship

Telephone Number

CREDENTIALING INFORMATION

NPI NumberCAQH Number

CAQH LoginCAQH Password

PERSONAL HEALTH

New York State Health Code requires a physical examination, including evidence of immunization status, for all Diagnostic & Treatment Center affiliated persons, to include members of the medical, dental, behavioral health and allied health professional staff. Written findings of your physical examination performed within the past twelve months will be required following approval for staff membership. This must be signed by the evaluating physician. Please note that a reassessment health evaluation must be completed annually and immunizations and tests updated as required per the Department of Health.

APPOINTMENT REQUESTED

Clinical Department

Medical Dental Behavioral Health

Practice Limitations (if any)

Special Interests (practice, research, teaching, or other)

Practice Affiliations Nature of each Affiliation

1. 1.

2. 2.

3. 3.

STATE LICENSING

  1. Have you ever applied for and been denied, not renewed, voluntarily relinquished, suspended revoked or any restrictions placed on your license in any state or country? Yes No
  2. Have you ever been sanctioned by any licensing board or any Federal, State or County Agency? Yes No

If yes to either question, please provide details on a separate sheet of paper.

List all past and present licenses and attach copies of current registration certificates.

State Number Current Yes NoExp Date

State Number Current Yes NoExp Date

State Number Current Yes NoExp Date

EDUCATION AND TRAINING

See CV

  1. UNDERGRADUATE EDUCATION

College or University

Address

CityStateCountry

Dates AttendedYear Graduated

DegreeHonors

  1. GRADUATE EDUCATION: School of Medicine, School of Dentistry, Graduate School

College or University

Address

City State Country

Dates Attended Year Graduated

Degree Honors

  1. FELLOWSHIP/PRECEPTORSHIP/INTERNSHIP Completed Yes No

InstitutionDates

Address

City/ State Country

Specialty Program Director

  1. TEACHING APPOINTMENT N/A

Facility Dates

Address City/ State

Type of Appointment Program Director

  1. CLINICAL RESIDENCY N/A

InstitutionDates

Address

City/ State Country

Specialty Program Director

InstitutionDates

Address

City/ State Country

Specialty Program Director

  1. EMERGENCY CARE TRAINING

Have you completed training in and have a current certification for the following:

CPR Yes NoACLS Yes No

ACLS Instructor Yes No ATLS Yes No

ATLS Instructor Yes NoPALS Yes No

NRP Yes No

Please attach copies of registration certificates.

V. SPECIALTY CERTIFICATIONN/A

Names of specialty boards by which you are certified:

1. Name

Date Recertification Due

2. Name

Date Recertification Due

If not board certified, have you applied for certification examination? Yes No

If no, do you intend to apply for certification examination? Yes No

Have you been accepted to take the certification examination? Yes No

If yes, what dates are you scheduled to take the certification examination

CONTROLLED SUBSTANCES

DEA Number Current Yes NoExp Date

PUBLICATIONS

See CV

List scientific papers, editorials, tests, chapters of texts and essays published or presented in the past three years. A separate sheet may be used if additional space is required.

PublicationDate

CHRONOLOGY OF PROFESSIONAL CAREER HOSPITAL AFFILIATIONS/EMPLOYMENT

See CV

NameDept. Head

AddressDept/Service/Job Title

Category Inclusive Dates

Current Yes NoIf No, Reason for discontinuation

Name Dept. Head

Address Dept/Service/Job Title

Category Inclusive Dates

Current Yes NoIf No, Reason for discontinuation

PROFESSIONAL LIABILITY DATA

Insurance Coverage

  1. Has your professional liability insurance coverage ever been terminated by an insurance company? Yes No
  2. Have you ever been denied professional liability insurance coverage?

Yes No

  1. If the answer to question 1 or 2 above is yes, state when and by what company:
  1. Has your present professional liability insurance carrier excluded any specific procedures from
    your coverage? Yes No
  2. If the answer to question 4 above is yes, 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.

Excluded ProceduresExplanation

Legal Actions

  1. Have any judgments or settlements been made against you in professional liability cases? Yes No
  1. Have any professional liability suits been filed against you which are presently pending? Yes No

If the answer to any of the above questions is yes, please provide a full explanation of the details on a separate sheet and attach. The explanation must include the name of the court in which the suit was filed, the caption and docket number of the case, and the name and address of the attorney defending you, and all other relevant details.

PROFESSIONAL HISTORY

  1. Has your license to practice ever been limited, suspended, denied, revoked, voluntarily surrendered, or subject to probationary conditions in any jurisdiction? Or, are you involved in such a pending action?

Yes No

  1. Has your DEA number ever been limited, suspended, revoked, or voluntarily surrendered?
    Or, are you involved in such a pending action? Yes No
  1. Has your membership, association, employment or practice at another facility ever been limited, suspended, denied, revoked, discontinued or voluntarily resigned? Or, are you involved in such pending action?

Yes No

  1. Have you ever been denied membership or privileges requested or renewal of membership or privileges or been subject to disciplinary action in any organization? Or, are you involved in such pending action? Yes No
  1. Have you ever been convicted of a crime or are you currently involved in any action, which could result in a criminal conviction? Yes No
  1. Have you ever been found guilty of professional misconduct, unprofessional conduct, incompetence or negligence in any state or country? Yes No
  1. Have you ever had charges against you for professional misconduct, unprofessional conduct, incompetence or negligence in any state or country? Or, are you involved in such a pending action? Yes No
  2. Has any hospital or licensed facility restricted or terminated your professional training, employment or privileges or have you ever voluntarily or involuntarily resigned or withdrawn from such association to avoid imposition of such measures? Yes No
  1. Are there currently pending against you any charges involving drug or alcohol related offenses?

Yes No

  1. Have you ever been the subject of a founded child abuse and maltreatment report?

Yes No

If the answer to any of the above is yes, please give full details on a separate sheet of paper.

JOB REQUIREMENTS

  1. Are you capable of performing the position’s essential job functions with or without accommodation? Yes No

Accommodation needed:

  1. Do you illegally use drugs? Yes No
  1. Have you used illegal drugs in the past five years? Yes No
  1. Some weekend, holiday and after hours coverage (10 evenings per month) is required.
    Is this acceptable to you? Yes No
  1. Are you presently credentialed by any of the following insurance companies?

Excellus Blue Cross Blue Shield Yes No Provider #

Guardian Yes No Provider #

MVP Yes NoProvider #

Child Health Plus Yes No Provider #

NYS Medicaid Yes No Provider #

Medicare Yes No Provider #

Tricare Yes No Provider #

GHP Yes No Provider #

MetLife Yes No Provider #

Guardian Yes No Provider #

Please list any other Insurance Companies with whom you are credentialed on a separate sheet of paper.

  1. Have you ever been denied as a provider by an insurance company? Yes No

If yes, please describe the substance of the action and resolution.

REFERENCES

Please provide the names of professional references. Avoid using professional partners or associates. References will be evaluated according to the extent of their direct clinical observation of your work and other knowledge of you.

NameTitle

Present position Position at the time of your association AddressPhone#

How long has this person known you? Relationship?

Name Title

Present position Position at the time of your association Address Phone#

How long has this person known you? Relationship?

Name Title

Present position Position at the time of your association Address Phone#

How long has this person known you? Relationship?

Name Title

Present position Position at the time of your association Address Phone#

How long has this person known you? Relationship?

STATEMENT OF APPLICANT

Acknowledgements

I understand and agree that I, as an applicant for medical/dental/behvaioral health staff membership or privileges, 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 fully understand that any significant misstatement in, or omissions from, this application constitutes cause for denial of appointment or cause for summary dismissal from the medical/dental/behavioral health staff. All information submitted by me in this application is true and accurate to my best knowledge or belief. I hereby signify my willingness to appear for interviews in regard to my application.

In making this application for appointment to the medical/dental/behavioral health staff of North Country Family Health Center, I acknowledge my obligation to provide continuous care and supervision of my patients and to accept other related assignments, including providing appropriate coverage for inpatients during any periods of absence.

I agree to conduct my practice in accordance with high ethical traditions. Specifically, I will not participate in any form of fee splitting. In complying with this principle, I understand that I am also not to collect fees from others referring patients to me, nor permit other physicians/dentists to collect fees for me, not to make joint fees and not to permit any associate of mine to do so.

I particularly agree to subject my clinical performance to, and faithfully participate in, the agency’s quality assurance/improvement program as the same shall, from time to time, be in effect and I agree to hold members of the medical/dental/behavioral health staff and other authorized representatives of North Country Family Health Center engaged in these quality activities free of all liability for their actions performed in good faith in connection therewith.

Provisional appointment shall be for a period of one year. Reappointment to the medical/dental/behavioral health staff will be annual, effective the first day of the year following the provisional status, providing satisfactory job performance, including meeting productivity standards.

I certify that I am qualified behaviorally, physically and by training to perform all procedures with sound judgment and technical skill for which I have requested clinical privileges. I further certify that all information provided in this application and/or to be provided in connection therewith is and will by true, complete and accurate in all respects and contains or shall contain no misstatement of a material fact necessary to make the statements made not misleading.

Signature of Applicant

Print Name Date

RELEASE FROM LIABILITY

I hereby release from liability all representatives of North Country Family Health Center, and its medical/dental/behavioral health staff for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications.

I hereby release from liability any and all individuals and organizations that provide information to North Country Family Health Center or its medical/dental/behavioral health staff in good faith and without malice concerning my professional competence, ethics, character and other qualifications for staff appointment and clinical privileges. I hereby consent to the release of such information to North Country Family Health Center by any hospital, physician, employer or educational institution with which I may have been associated or to which I may have applied for association.

I hereby further authorize North Country Family Health Center to communicate to other persons or organizations with a legitimate professional interest therein such information as may be required under state law and the Diagnostic and Treatment Center Regulations concerning my professional competence, character and ethics that North Country Family Health Center may have or acquire, and where such communication is made in good faith and without malice, I consent thereto and agree to hold the agency and its authorized representatives free of liability therefore.

Signature of Applicant

Print Name Date

1