Requestfor Application Questionnaire

Form #1

Requestfor Application Questionnaire

Date: «ProviderDemographics.CurrentDate»

Name in Full: «ProviderDemographics.ProviderFullName_FN»«ProviderDemographics.Title»

Office Address:«ProviderDemographics.PracName», «ProviderDemographics.PracAdd1», «ProviderDemographics.PracAdd2», «ProviderDemographics.PracCity», «ProviderDemographics.PracSt»«ProviderDemographics.PracZip»

Office Telephone:

Residence Address:

Residence Telephone:

(1)Please indicate the medical staff category to which appointment is desired.

Category:

(See excerpt from Medical Staff Bylaws)

(2)Please indicate your clinical specialty, as well as any procedures or privileges outside of that specialty area that you would like to request.

Specialty:

Additional Clinical Privileges:

(3)Do you plan to establish or have you established an office near the hospital?

Yes _____ No _____ Where?

When will office hours begin at that location?

(4)Are you currently appointed to the medical staff of any other hospitals?

Yes _____ No _____ If yes, please list.

Hospital Category:

Address

Hospital Category:

Address

(5)Are you planning to apply for appointment and clinical privileges at any other hospital(s)? If yes, please list.

Yes _____ No _____

Hospital Category:

Address

Hospital Category:

Address

(6)Do you participate in:

(a)Medicare?Yes _____ No _____

(b)Medicaid?Yes _____ No _____

(c)(affiliated) Health Plan? (if applicable)Yes _____ No _____

(7)Are there currently any restrictions on your state license or is it currently subject to any probation or conditions?

Yes_____ No _____

(8)Are there currently any restrictions on your DEA registration (or state controlled substance license, if applicable)?

Yes _____ No _____

(9)Have you ever been convicted of Medicare, Medicaid, or other federal or state governmental or private thirdparty fraud or program abuse, or been required to pay civil money penalties for the same, or been excluded or precluded from such programs?

Yes _____ No _____

(10)Have you ever been convicted of, or pled guilty or no contest to, any felony, or any misdemeanor relating to violence, controlled substances, illegal drugs, insurance or health care fraud or abuse?

Yes _____ No _____

(11)Has your medical staff appointment, any clinical privileges or status as a participating provider ever been denied, revoked, relinquished, restricted, or terminated by any hospital or health plan for reasons related to clinical competence or professional conduct?

Yes _____ No _____

(12)Have you ever resigned medical staff appointment or relinquished clinical privileges during a medical staff investigation or in exchange for not conducting such an investigation?

Yes _____ No _____

(13)Are you able to demonstrate recent clinical activity in your primary area of practice during the last two years?

Yes _____ No _____

(14)Are you employed by any other hospital or its affiliate?

Yes _____ No _____ If yes, please list:

(15)Do you have any ownership or investment interests in, or compensation arrangement or contract with, any health care provider?

Yes _____ No _____ If yes, please list:

(16)If appointed to the medical staff, will you agree to participate in the emergency call rotation and to treat all patients referred to you regardless of ability to pay?

Yes _____ No _____

This form must be returned with copies of the following documents:

(a)Current license(s) to practice your profession;

(b)Current DEA registration (and state controlled substance license, if applicable);

(c)Certificate of coverage from professional liability insurance carrier;

(d)ECFMG certificate (if foreign medical graduate);

(e)Evidence of successful completion of an approved postgraduate residency program;

(f)Evidence of Board certification status;

(g)Government-issued photo identification (passport, driver’s license); and

(h)A current curriculum vitae.

I request an Application for Appointment and Clinical Privileges. I certify that I meet the prerequisites for receiving an application. I understand that the information requested on this Request for Application Questionnaire is sought to enable the hospital to determine whether I am eligible to receive an application. The Request for Application Questionnaire does not constitute an application.

I hereby release from any and all liability, and agree not to sue, the hospital and its representatives for their actions in connection with evaluating the information provided on this questionnaire and determining whether I am eligible to receive an application. I understand that a determination that I am not eligible to receive an application does not give rise to any hearing rights.

DateSignature

Medical Staff Leader HandbookRequest for Application Questionnaire - 1

If the answer to the question is “yes,” please explain on a separate sheet and attach.

Consult with legal counsel to determine whether this question is permissible in your state.