UWMC/SCCA Patient Care Services Credentialing

Application to Practice continued

University of WashingtonMedicalCenter

Seattle Cancer Care Alliance

Patient Care Services: Credentialing

Application to Practice

I am renewing privileges at (please check one or both): UWMC SCCA

Applicant Name:
Position Title:
Birth Date: / *UW ID# / Not needed for renewal
*Last 6 digits of SSN
(non-UW employees only) / Not needed for renewal
Employer:
Work Address:
(include UW/SCCA/
FHCRC Box #)
Work Phone:
Work Fax:
E-mail:
Residence Address:
Residence Phone:

Current licensure, registration, or certification for the State of Washington:

RN license / Health Care Assistant certification specific to current role & supervisor
ARNP license / Other certification/registration/licensure (describe):
License Number(s):

Professional Liability Insurance (further information may be required):

Insurance is provided through my employer
NOTE: Individuals are covered by UW liability insurance if they are employed by a UW-managed agency, they are acting within their job description, and they receive their paycheck from the UW.
Insurance is provided through an individual policy
NOTE: Individuals need individual policies if liability insurance is not provided by their employer.

Have you ever had any claims against your practice? no yes (attach explanation)

Applicant Name:

Please complete one or both of the following agreements, depending on which organization(s) you will be working with.

UWMC AGREEMENT

I authorize UWMC Patient Care Services to obtain my immunization records for the purpose of credentialing at UWMC.

I agree to adhere to the following UWMC organizational expectations while at UWMC:

  1. Maintain patient confidentiality in accordance with UWAMC Confidentiality Data Security and Patient Confidentiality Understanding.
  2. Obtain information about and orientation to UWMC documentation system(s) relevant to my proposed role.
  3. Obtain and wear a UWMC nametag whenever in the medical center, if required by my role.
  4. Adhere to UWMC dress code, maintaining an appearance of professionalism.
  5. Read and comply with the attached orientation packet prior to interacting with patients.

UWMC Dress Code

“Patient Rights and Responsibilities” pamphlet

Emergencies & Workplace Safety Information

  1. Communicate with patient’s nurse and/or unit/area charge nurse prior to patient contact.

Signature of applicant: / Date:

SCCA AGREEMENT

I authorize UWMC Patient Care Services to obtain my immunization records for the purpose of credentialing at SCCA.

I agree to adhere to the following SCCA organizational expectations while at SCCA:

  1. Maintain patient confidentiality in accordance with SCCA Confidentiality Policy statement.
  2. Obtain information about and orientation to SCCA documentation system(s) relevant to my proposed role.
  3. Obtain information about and follow SCCA policies relevant to my proposed role.
  4. Obtain and wear a SCCA nametag whenever in the clinic.
  5. Adhere to SCCA dress code, maintaining an appearance of professionalism.
  6. Communicate with patient’s nurse and/or unit/area charge nurse prior to patient contact.

Signature of applicant: / Date:

Rev. 10/03