Application dateStart dateSpecialty
Name: Last FirstMiddle
List all other names used in the last 7 years:
Date of BirthDrivers License NumberState issued
Current Home Address
CityStateZip
Primary Office Address;
Were you previously affiliated with (Name of Hospital)? Yes No
CURRENT PRACTICE AFFILIATION Years of Employment/Staff membership:
Name of Facility:
Contact information of one reference in current place of practice or employment who can attest to your qualifications to practice or provide service.
Name: Contact info:
Please list the city, state, and zip you have lived or worked in for the past 7 years with approximate dates:
DatesCityStateZip
DatesCityStateZip
DatesCityStateZip
Office phone number ( )Cell Phone number ( )Email Address
FAX and Exchange numbers:
BOARD CERTIFICATION status-if you are not board certified, what is your current status in the certification process?
Date scheduled for exam
Name of BoardDate certifiedExpiration date
Name of
Subspecialty BoardDate certifiedExpiration date
Are you affiliated with other physician(s) group(s)? If so, who?
Have you taken time away from medical Practice? When, and for what reason?
Are you currently retired or providing patient care in the office setting only? If so, for how long?
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CLINCAL EXPERIENCE:California Board License # Expiration date:
DEA Registration # Expiration date:
Professional Liability Carrier: Policy # Expires:
Unique Physician Identification #:
Medical Privileges / √ Requested Privileges
Cardiology / Gastroenterology / Nephrology / Psychiatry/Clin Psychology
Critical Care / Infectious Diseases / Neurology / Pulmonary Disease
Emergency Department / Internal Medicine / Pediatrics / Radiology
Family Medicine / Neonatology / Pediatrics / Other:
Surgical Privileges / √ Requested Privileges
Anesthesiology / Ophthalmology / Pathology / Thoracic Surgery
General Surgery / Oral/maxillofacial / Pediatric Surgery / Urologic Surgery
Neurological Surgery / Orthopedic Surgery / Plastic Surgery /
Obstetrics/Gynecology / Otolaryngology / Podiatry /
AVAILABILITY & AFFILIATION
Indicate your availability:
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Times of day you may be available
Are you registered with a volunteer organization? If yes, select below:
Disaster Healthcare Volunteers Medical Reserve Corps Other, specify
California Medical Assistance Team Disaster Medical Assistance Team
DISCIPLINARY ACTIONS: (check ( √ ) and explain in detail any disciplinary actions taken against you for any of the following):
Medical License in any state
DEA controlled substance registration
Membership or clinical privileges on any hospital medical staff
Professional society/fellowship or Board Certification membership
Any other type of professional sanction
Professional liability insurance
Felony charges brought against you
Government sanctions
Please explain:
NEXT OF KIN & EMERGENCY CONTACT
Name, phone number and relationship of two individuals to contact in the event of an emergency.
Name / Telephone Number / Relationship
1. / ( )
2. / ( )
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PLEASE READ CAREFULLY
DISCLOSURE AND AUTHORIZATION FORM
(Name of Hospital) (the “Company”) will procure a consumer report and/or investigative consumer report on you in connection with your employment application. (Name of Company), or another consumer reporting agency, will obtain the report for the Company. Pre-employ.com, Inc.
The report will contain information bearing on your character, general reputation, personal characteristics, and mode of living. The types of information that may be obtained include but are not limited to: social security number verification, criminal records checks, public court records checks, driving records checks, educational records checks, verification of employment positions held, personal and professional references checks, licensing and certification checks, etc. The information contained in the report will be obtained from private and/or public record sources, including sources identified by you or through interviews or correspondence with your past or present coworkers, neighbors, friends, associates, current or former employers, educational institutions or other acquaintances.
The nature and scope of any investigative consumer reports that may be requested is explained above. You are nonetheless entitled to request more information about the nature and scope of such reports by submitting a written request to: Compliance Department, P.O. Box 491570, Redding, and Ca. 96049 or faxed to 888-999-3839.
The Company is furnishing you with a summary of your rights under the Fair Credit Reporting Act in a form prescribed by the Federal Trade Commission.
ADDITIONAL STATE LAW NOTICES
If you live or are applying for a job in the state of California, Maine or New York, please review these additional notices.
CALIFORNIA: You may view the file maintained on you by Pre-employ.com, Inc. You may also obtain a copy of this file, upon submitting proper identification and paying the costs of duplication services, by appearing at Pre-employ.com, Inc. offices in person, during normal business hours and on reasonable notice, or by mail; you may also receive a summary of the file by telephone. Pre-employ.com, Inc. has trained personnel available to explain your file to you, including any coded information. If you appear in person, you may be accompanied by one other person, provided that person furnishes proper identification.
MAINE: You have the right upon request, to be informed of whether an investigative consumer report was requested, and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request and receive from the Company, within five business days of our receipt of your request, the name, address and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such consumer reporting agencies copies of any such investigative consumer reports.
NEW YORK: You have the right, upon written request, to be informed of whether or not an investigative consumer report was requested. If a consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by contacting that agency.
AUTHORIZATION
I have carefully read and understand this Disclosure and Authorization form. By my signature below, I consent to the release of consumer reports and investigative consumer reports prepared by a consumer reporting agency, such as Pre-employ.com, Inc. to the Company. I understand that if the Company hires me, my consent will apply throughout my employment unless I revoke or cancel it by sending a signed letter to Compliance Department, P.O. Box 491570, Redding, Ca. 96049 or faxed to 888-999-3839.
I understand that, to the extent allowed by law, information contained in my job application or otherwise disclosed by me before, during or after my employment, if any, may be utilized for the purpose of obtaining consumer reports or investigative consumer reports.
By my signature below, I also authorize the disclosure of information concerning my employment history, earnings history, education, motor vehicle history and standing, criminal history, and all other information deemed pertinent by the consumer reporting agency to the agency by the following: past or present employers; learning institutions, including colleges and universities; law enforcement agencies; federal, state and local courts; the military; and, motor vehicle records agencies.
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For residents of, or for jobs located in California, Minnesota and Oklahoma only: You will be provided with a free copy of any consumer reports or investigative consumer reports if you check the box below. You may obtain information or copies from the Company’s investigative report file at any time prior to your receipt of such copies, to the extent available, by contacting Compliance Department, P.O. Box 491570, Redding, Ca. 96049 or by toll free fax 888-999-3839.
I request a free copy of the report.
Occasionally, Pre-employ.com and/ or its partners send information on identity theft protection, background check information and other related products or services.
I DO____ or I DO NOT____ wish to receive this information via email or mail.
- I certify that the statements made and submitted for review are accurate.
- I understand that the hospital is not obligated to grant me Temporary Disaster privileges, but that said privileges will be approved on a case-by-case basis by the Chief of Staff (or his designee) and the Chief Executive Officer (or his designee) in accordance with the needs of the organization and its patients, and based upon my qualifications as volunteer licensed independent practitioner.
- I will be paired with a currently credentialed medical staff member of a similar specialty and shall act only under the direct supervision of a medical staff member.
- If granted, Temporary Disaster privileges will automatically be cancelled at the end of needed services and will not give rise to a hearing or review.
Signature: Date:
CRITERIA TO BE MET:
Emergency Operations Plan has been activated and hospital is unable to meet the immediate patient load.
ITEMS VERIFIED:
Valid government-issued photo identification, such as driver’s license or passport
and, at least one of the following:
A current picture identification card from a health care organization that clearly identifies professional designation
A current license to practice
Primary source verification of licensure (with Medical Board)
Identification that the individual is a member of DMAT, MRC, ESAR-VHP, or other recognized state or federal organization or
Group
Identification that the individual has been granted authority by a government entity to provide patient care, treatment and services
in disaster circumstances.
Confirmation by a LIP currently privileges by the hospital or by a staff member with personal knowledge of the volunteer
practitioner’s ability to act as a LIP during a disaster.
And
Evidence of malpractice insurance in amount of $1/3 million – waived by the Board of Directors whenever a state of emergency
has been declared by local, state, or federal government agencies.
The above items have been photocopied and are attached to this checklist. If not, explain why:
Signature, Medical Staff Credentialing UnitDate / Time
APPROVED BY:
President, Medical Staff (or designee)
President/CEO (or designee)
DISTRIBUTION: Cardiology; Cath Lab: Emergency: In-Service Education; Lab; Medical Records; Medical Transcription; Nursing Administration/2-Pavilion/NICU/Pediatrics; Perinatal; Pharmacy; Quality Improvement; Radiology; Respiratory; Same Day Surgery; Spine Center; Surgery; Wound Healing Center; (Name) (MSO) Need to individualize departments for distribution
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PRIVACY, INFORMATION SECURITY AND CONFIDENTIALITY
I understand and acknowledge that in the course of my employment or involvement with (Name of Hosptal), or any of its related entities, collectively referred to as (“Organization”), there will be times when I will see, hear, or otherwise have access to confidential and private information such as patient health information, whose privacy and security I must maintain. To that end, I understand and acknowledge that:
- I agree to preserve and protect the privacy, confidentiality and security of all confidential information relating to the Organization, its patients, activities and affiliates, in accordance with applicable state and federal laws, including but not limited to the Health Information Portability and Accountability Act (HIPAA), and the Organization’s policies.
- I will only access, use or disclose confidential information only in the performance of my duties for the Organization, when required or permitted by law, and disclose information only to persons who have the right to receive that information. When using or disclosing confidential information, I will use or disclose only the minimum information necessary.
- The Organization is committed to protecting patient privacy and keeping patient information confidential and secure. I support this obligation during the course of my employment or involvement with the Organization. How I treat, protect, and secure confidential information applies even when I am not at the Organization.
- I recognize that posting, transferring, or reproducing patient health information on the internet such as on a social media or networking site or on any electronic or mobile device or via electronic communication methods (e.g. email, text, or instant messaging) without appropriate authorization is not allowed and may compromise the privacy and security of that information and subject me to disciplinary and/or legal action.
- If I am provided a user name / log in and password to access any of the Organization’s electronic medical record, billing and financial, or other computer or information systems, I understand that it is my responsibility to follow safe computing guidelines. To this end, I agree not to share my user name / log in and/or password with any other person. I am responsible for any potential breach of confidentiality or privacy resulting from access made to the Organization’s electronic information systems (including mobile devices) using my user name / log in and password. If I believe someone else has used my user name / log in or password, I will immediately report the use to the appropriate information technology department and request a new password. My user name / log in and password constitutes my signature and I will be responsible for all entries made under my user name / log in. I agree to always log off shared workstations and lock personal workstation if left unattended.
- I understand that my access to any of the Organization’s electronic information systems is subject to audit in accordance with the Organization’s policies.
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- Under state and federal laws and regulations and the Organization’s policies governing a patient’s right to privacy, unlawful or unauthorized access to, or use or disclose of, patients’ confidential patient information may subject me to disciplinary action up to and including immediate termination from my employment/professional relationship with the Organization, civil fines for which I will be personally responsible, and criminal sanctions.
- I agree to report to the Organization’s management, the HIPAA Privacy Officer, and/or HIPAA Security Officer any instance where I suspect that the Organization’s privacy or security policies are being violated or where the security or privacy of the Organization’s confidential or patient information may be compromised.
I have read, understand and acknowledge all of the above PRIVACY, INFORMATION SECURITY AND CONFIDENTIALITY; Acknowledgement of Responsibility
SignaturePrint NameDate
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Attestation of Orientation for Disaster Volunteer
Print Name:
Unit Assignment:
Sign and return this form prior to starting your shift.
By signing below, I attest that I have reviewed the Disaster Volunteer Orientation Packet in its entirety and take responsibility for the information contained therein. If I have any questions regarding the material in the orientation packet, I will seek clarification from the person in charge of my assigned area prior to starting my first shift at (Name of Hospital).
SignatureDate
DISASTER VOLUNTEER LIABILITY RELEASE FORM
I, ______, have been approved by (Name of Hospital) for the following:
Disaster Volunteer Assignment______
All consequences of such above-mentioned selection, including any actions that occur on or off hospital grounds, rest solely with the participant. I understand that (Name of Hospital) is not responsible or liable for any actions taken while participating in the Disaster Volunteer assignment. I agree to hold the hospital harmless from any potential injuries that I may sustain while engaged in any action or activity necessitated by the Disaster Volunteer assignment.
Participant Signature:
Participant Contact Number:
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