1 MEDICAL STAFF APPOINTMENT CHECKLIST **Please complete entire application. Statements such as see attached are not acceptable and will be returned for completion. In order to process your application in an expeditious fashion, please enclose all of the items listed below. Please contact Sherri in the Medical Staff Office ( ) should you have any questions. To be appointed to Ohio Valley General Hospital's Medical Staff, the following items must be sent in the enclosed return envelope: A check for $ made payable to Ohio Valley General Hospital Medical Staff (processing fee) Application for Appointment to the Medical Staff, completed, signed & dated Health Status Questionnaire, signed & dated Delineation of Clinical Privileges with requested privileges, sign and dated on page 36 Copy of current Pennsylvania Medical/Dental License Explanation of any restrictions Organizational and Professional Ethics signed and dated Acknowledgment of Organized Health Care Arrangement signed on page 2 (HIPPA Regulations) Proof of malpractice insurance Copy attached Copy of DEA registration certification Explanation of any restrictions List of Continuing Medical Education Seminars that are pertinent to privileges with the dates attended and the number of credits earned Copy of board certification, if applicable Copies of any certificates and/or membership cards to any professional societies, if applicable Physician Signature Sample Form, signed Medicare Payment Form, signed & dated Copy of recent PPD Testing Thank you. Thank you.
2 APPLICATION FOR APPOINTMENT TO THE MEDICAL STAFF Medical Staff membership or clinical privileges will not be denied on the basis of race, color, religion, age, sex, national origin, ancestry, or practice-related disability. Please type or print all information including addresses and phone numbers and return by. If not completed and postmarked by this date, the Application shall be considered void. LAST NAME FIRST NAME MIDDLE INITIAL SPECIALTY DEGREE PRIMARY OFFICE ADDRESS TELEPHONE FAX OTHER OFFICE ADDRESS TELEPHONE FAX HOME ADDRESS TELEPHONE ADDRESS CITIZENSHIP MARITAL STATUS ECFMG REG. DATE OF BIRTH PLACE OF BIRTH SOCIAL SECURITY NUMBER 9 M 9 S 9 D 9 W ASSOCIATIONS IN PRACTICE (WITH WHOM AND NATURE OF AFFILIATION) LIST IN CHRONOLOGICAL ORDER ALL HOSPITAL/INSTITUTIONAL AFFILIATIONS INCLUDING MILITARY ASSIGNMENTS HOSPITAL / INSTITUTION STREET ADDRESS DEPT. STAFF CATEGORY DATES (mm/yy) 1. FROM TO 2. FROM TO 3. FROM TO 4. FROM TO 5. FROM TO PENNSYLVANIA LICENSE NUMBER (ATTACH CURRENT COPY) - - PLACE PASSPORT PHOTO HERE DEA REGISTRATION NUMBER (ATTACH COPY OF DEA CARD) UPIN NUMBER (IF APPLICABLE) NPI NUMBER MEDICARE NUMBER (IF APPLICABLE) TAX ID NUMBER - FOR OFFICIAL USE ONLY: DATE SENT: DATE RECEIVED:
3 NAME: DATE: MEDICAL/DENTAL SCHOOL DATE BEGAN: (mm/yy) DATE OF GRADUATION: ( mm/yy) DEGREE PROFESSIONAL SCHOOL DATE BEGAN: (mm/yy) DATE OF GRADUATION (mm/yy) DEGREE+ COLLEGE OR UNIVERSITY DATE BEGAN:(mm/yy) DATE OF GRADUATION:(mm/yy) DEGREE OTHER EDUCATION AND TRAINING (LIST IN CHRONOLOGICAL ORDER: INTERNSHIPS, RESIDENCIES, FELLOWSHIPS, PRECEPTORSHIPS, TEACHING APPOINTMENTS AND POST-GRADUATE EDUCATION. ACCOUNT FOR ALL TIME SINCE GRADUATION FROM MEDICAL SCHOOL) 1. HOSPITAL / INSTITUTION SPECIALTY DATES: (mm/yy) TYPE (INTERNSHIP, RESIDENCY, ETC.) CHIEF OF SERVICE FROM TO 2. HOSPITAL / INSTITUTION SPECIALTY DATES: (mm/yy) TYPE (INTERNSHIP, RESIDENCY, ETC.) CHIEF OF SERVICE FROM TO 3. HOSPITAL / INSTITUTION SPECIALTY DATES (mm/yy) TYPE (INTERNSHIP, RESIDENCY, ETC.) CHIEF OF SERVICE FROM TO 4. HOSPITAL / INSTITUTION SPECIALTY DATES (mm/yy) TYPE (INTERNSHIP, RESIDENCY, ETC.) CHIEF OF SERVICE FROM TO 5. HOSPITAL / INSTITUTION SPECIALTY DATES (mm/yy) TYPE (INTERNSHIP, RESIDENCY, ETC.) CHIEF OF SERVICE FROM TO
4 NAME: DATE: MEDICAL / DENTAL / PROFESSIONAL LICENSES NUMBER STATE DATE ISSUED BOARD CERTIFICATION (ATTACH A COPY OF BOARD CERTIFICATION OR ADMISSIBILITY) ARE YOU BOARD CERTIFIED? YES 9 NO 9 BOARD STATUS DATES--FROM/TO MEMBERSHIP IN PROFESSIONAL SOCIETIES (ATTACH COPIES OF ANY CERTIFICATES AND/OR MEMBERSHIP CARDS FOR ANY PROFESSIONAL SOCIETIES) NAME DATES OFFICES NAME AND ADDRESS OF PRESENT CARRIER LIABILITY INSURANCE POLICY NUMBER COVERAGE AMOUNT EXPIRATION DATE RESTRICTIONS HAS YOUR PROFESSIONAL LIABILITY COVERAGE EVER BEEN TERMINATED BY ACTION OF AN INSURANCE COMPANY? YES 9 NO 9 IF YES, WHEN AND BY WHAT COMPANY LEGAL ACTIONS HAVE ANY PROFESSIONAL LIABILITY CLAIMS EVER BEEN FILED AGAINST YOU? YES 9 NO 9 IF YES, PROVIDE A FULL EXPLANATION OF THE DETAILS. PLEASE ANSWER EACH OF THE FOLLOWING QUESTIONS. IF THE ANSWER TO ANY OF THE QUESTIONS IS YES, PROVIDE A FULL EXPLANATION OF THE DETAILS. 1. HAVE ANY DISCIPLINARY ACTIONS EVER BEEN TAKEN OR ARE ANY PENDING AGAINST YOU BY ANY STATE LICENSURE BOARD? YES 9 NO 9 2. HAS YOUR LICENSE TO PRACTICE IN ANY STATE EVER BEEN LIMITED, SUSPENDED, REVOKED, OR VOLUNTARILY OR INVOLUNTARILY RESTRICTED? 3. HAS YOUR PARTICIPATION IN ANY PRIVATE, FEDERAL OR STATE INSURANCE PROGRAM EVER BEEN SUSPENDED, SANCTIONED, RESTRICTED OR VOLUNTARILY OR INVOLUNTARILY LIMITED? YES 9 NO 9 YES 9 NO 9 4. HAS YOUR DEA NUMBER EVER BEEN RESTRICTED, SUSPENDED, REVOKED OR VOLUNTARILY OR INVOLUNTARILY LIMITED? YES 9 NO 9 5. HAS YOUR EMPLOYMENT, APPOINTMENT OR PRIVILEGE S AT ANY HOSPITAL OR OTHER INSTITUTION EVER BEEN RESTRICTED, SUSPENDED, REVOKED, REFUSED, OR VOLUNTARILY OR INVOLUNTARILY LIMITED? 6. HAVE YOU EVER BEEN DENIED MEMBERSHIP (OR RENEWAL THEREOF) OR BEEN SUBJECT TO ANY DISCIPLINARY PROCEEDINGS BY ANY PROFESSIONAL SOCIETY? 7. HAVE YOU EVER VOLUNTARILY, INVOLUNTARILY WITHDRAWN OR LIMITED STAFF MEMBERSHIP AT ANY HOSPITAL OR WITHDRAWN YOUR APPLICATION FOR STAFF PRIVILEGES? 8. HAVE YOU EVER BEEN CONVICTED OF A CRIME OTHER THAN A MINOR TRAFFIC VIOLATION? IF YES, PLEASE ATTACH AN EXPLANATION. YES 9 NO 9 YES 9 NO 9 YES 9 NO 9 YES 9 NO 9
5 NAME: DATE: PEER RECOMMENDATIONS: LIST THREE PRACTITIONERS IN THE SAME SPECIALTY AS YOURS WHO ARE FAMILIAR WITH YOUR WORK AND WHO THE HOSPITAL MAY CONTACT FOR REFERENCES. PLEASE PRINT CLEARLY REFERENCE 1 REFERENCE 2 REFERENCE 3 NAME SPECIALTY STREET ADDRESS CITY STATE/ZIP PHONE NUMBER FAX NUMBER STAFF CATEGORY AND PRIVILEGE PROGRAM REQUESTS DEPARTMENT REQUESTED 9 ANESTHESIOLOGY 9 OBSTETRICS / GYNECOLOGY/PEDIATRICS 9 SURGERY 9 EMERGENCY MEDICINE 9 PATHOLOGY / NUCLEAR MEDICINE 9 MEDICINE 9 RADIOLOGY STAFF CATEGORY REQUESTED 9 ACTIVE 9 PROCEDURE SPECIFIC 9 PART-TIME EMERGENCY 9 CONSULTING 9 COURTESY 9 HONORARY
6 I fully understand that any significant mis-statements in or omission from this application constitute cause for denial of appointment or cause for summary dismissal from the Medical Staff. All information submitted by me in this application is true to my best knowledge and belief. In making this application for appointment to the Medical Staff of this Hospital, I acknowledge that I have read the Bylaws, Rules and Regulations of the Medical Staff of this Hospital, and that I am familiar with the principles and standards of CMS, Joint Commission on Accreditation of Healthcare Organizations and the principles, standards and ethics of the national, state and local associations that apply to and govern my specialty and/or profession, and I agree to be bound by the terms thereof without regard to whether or not I am granted membership or clinical privileges in all matters relating to the consideration of my application for appointment to the Medical Staff, and I further agree to abide by such Hospital and staff rules and regulations as may be from time to time enacted. By applying for appointment to the Medical Staff, I hereby signify my willingness to appear for the interviews in regard to my application, authorize the Hospital, Medical Staff and their representatives to consult with administrators and members of medical staffs of other hospitals or institutions with which I have been associated and with others, including past and present malpractice carriers, who may have information bearing on my professional competence, health character and ethical qualifications. I hereby further consent to the inspection by the Hospital, its Medical Staff and its representatives of all records and documents, including medical records, at other Hospitals, treating physicians and psychiatrists on an ongoing basis. I further agree to provide the Hospital at their request any appropriate authorization for the release of the aforementioned information, that may be material to an evaluation of my professional qualifications and competence to carry out the clinical privileges requested as well as my moral and ethical qualifications for staff membership. I hereby release from any liability any and all individuals and organizations who provide information to the Hospital or its Medical Staff in good faith and without malice concerning my professional competence, ethics, character, and other qualifications for staff appointment and clinical privileges; and I hereby consent to the release of such information. I further authorize and instruct my medical malpractice insurance provider to release information to the Hospital regarding my coverage and to notify the Hospital in the event my insurance is canceled or not renewed. I hereby further authorize and consent to the release of information by this Hospital or its Medical Staff to other hospitals, medical associations and other interested persons on request regarding any information the Hospital and the Medical Staff may have concerning me as long as such release of information is done in good faith and without malice; and I hereby release from liability this Hospital and its staff for doing so. I understand and agree that I, as an applicant for Medical Staff membership, have the burden of procuring adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications, and for resolving any doubts about such qualifications. I pledge to provide timely, adequate and continuous care for my patients, or in my absence, through prior arrangements with an eligible alternate practitioner of at least equivalent privileges. I have not requested privileges for any procedures for which I am not certified. Furthermore, I realize that certification by a board does not necessarily qualify me to perform certain procedures. However, I believe that I am qualified to perform all procedures for which I have requested privileges. I agree to serve on-call to the Emergency Department in my specialty. I will not order the transfer of any patient who presents to the Emergency Department without personally examining the patient, complying with all applicable legal requirements and placing the patient s medical needs above all other consideration. I understand that failure to meet this requirement will result in my ineligibility to reapply. PRINTED NAME: DATE: SIGNATURE:
7 OHIO VALLEY GENERAL HOSPITAL NOTICE OF ORGANIZED HEALTH CARE ARRANGEMENT BETWEEN HOSPITAL AND MEDICAL STAFF Ohio Valley General Hospital, the independent contractor members of its Medical Staff (including your physician), and other health care providers affiliated with Ohio Valley General Hospital have agreed, as permitted by law, to share your health information among themselves for purposes of treatment, payment or health care operations. This enables us to better address your health care needs. This notice is being provided to you as a supplement to the Notices of Privacy Practices already given to you by Ohio Valley General Hospital and by your health care provider. *Please sign the attached form
8 OHIO VALLEY GENERAL HOSPITAL ACKNOWLEDGMENT OF ORGANIZED HEALTH CARE ARRANGEMENT The following acknowledgment should be signed by all Medical Staff members and anyone else exercising clinical privileges. It should also be added to application forms for appointment/reappointment to the Medical Staff to help ensure that applicants are aware of and understand their obligations as part of an Organized Health Care Arrangement. The undersigned agrees that, with respect to activities at Ohio Valley General Hospital, the undersigned shall be considered as part of an Organized Health Care Arrangement with Ohio Valley General Hospital as that term is defined at 45 C.F.R The undersigned shall comply with all Ohio Valley General Hospital policies and federal and state laws and regulations relating to the use and disclosure of individually identifiable health information, and shall adopt such procedures and comply with such policies as may be required from time to time. The undersigned agrees to inform all patients that he or she is participating in an Organized Health Care Arrangement with Ohio Valley General Hospital and to give each patient a Notice of Organized Health Care Arrangement as provided by Ohio Valley General Hospital. Printed Name Signature Date
9 SUPPLEMENT TO THE APPLICATION FOR APPOINTMENT TO THE MEDICAL STAFF HEALTH STATUS QUESTIONNAIRE Please complete this questionnaire and return with your application for Medical Staff Membership. If you answer YES to any of the following questions, detail in #6 below. Use the back of this page for further information as needed YES 9 NO Do you have any physical handicap which could limit your ability to fully practice in your medical or surgical field (which would prevent you from safely exercising the privileges you have requested)? 2. 9 YES 9 NO Are you currently having any medical and/or psychiatric problems which would prevent you from safely exercising the privileges you requested (including alcohol or drug dependence)? 3. 9 YES 9 NO Have you been hospitalized or institutionalized during the past five years? 4. 9 YES 9 NO Do you have any continuing health problems requiring current therapy? 5. Please indicate any special accommodations that may be required in order for you to practice at Ohio Valley General Hospital: 6. Please detail any YES responses from above: Name Signature Date
10 ORGANIZATIONAL AND PROFESSIONAL ETHICS: Physician Certification and Agreement of Compliance Ohio Valley General Hospital has an ethical responsibility to the patients and community it serves and to those government agencies that regulate the Hospital. In order to support an ethical framework for business and patient care operations, the Hospital has adopted an ethical behavior policy. This policy is intended to guide the actions of the Hospital s Board members, Administration, Directors, Medical Staff and employees. Any violation of applicable law or deviation from these ethical standards will result in disciplinary action. Questions or concerns regarding these standards or Ohio Valley s commitment to maintaining ethical business and patient care practices should contact the Hospital s compliance officer. I. Advertising and Marketing Advertising and marketing programs will represent the Hospital s services accurately and in a non-deceptive manner. These programs will further refrain from innuendo and/or disparaging comments regarding competitors. Ohio Valley will not seek to solicit patients for services beyond its mission, scope or licensure. II. Billing Practices Patient billing procedures will adhere to Board-approved rate schedules. Rate schedules will be consistently applied to all payors. An Itemized statement of all charges, inclusive of service date and description, will be made available to all patients. The Hospital will bill patients and third parties for services actually provided and will periodically audit its billing systems. Contracted discounts will be subject to Administrative oversight. The Hospital will provide financial counseling to help patients understand the implications of the cost of their care. The Hospital will attempt to resolve billing questions or conflicts to the satisfaction of the patient while considering the best interest of the Hospital. III. Financial Records Anyone involved in creating, processing, or recording financial information, patient care information or any other patient-related documentation will be responsible for its accuracy and integrity. Accounting, financial, patient care, and billing entries will reflect supporting documentation. No information will be concealed from or by Hospital management or its internal or independent auditors. No information will be concealed from fiscal intermediaries of government programs. The financial position of the Hospital will be recorded in accordance with legal and regulatory requirements as well as generally accepted accounting principles. Cost reports for reimbursement under government programs will be completed accurately and in accordance with established procedures and regulations that define reimbursable costs. Errors or omissions related to cost reports will be promptly reported to the Hospital s compliance officer.
11 IV. Confidential Information Proprietary and/or confidential business information that has been developed or acquired by the Hospital and is not generally available to others must not be discussed with competitors or any person who might be in a position to disclose such information to a competitor. The confidentiality of patient information including medical records will be strictly maintained. Employees may not discuss a patient s medical condition or provide any information about a patient to anyone other than Hospital personnel who need the information or other authorized persons. The Hospital will treat any violation of patient confidentiality as a very serious matter. V. Gratuities and Customer Gifts Acceptance of gifts of a nominal value or reasonable personal entertainment is not improper if the giver has no intent to influence your judgment. A gift to a customer is appropriate only if (1) the monetary value is modest, (2) the benefit is part of a marketing or educational activity or (3) the benefit does not violate laws. Acceptable gifts include promotional items of limited value or an occasional business meal. VI. Contractual Arrangements The Hospital will contract with other organizations or individuals on a basis of mutual respect and prudence. The Hospital will seek to be a prudent purchaser by pursuing competitive bids and joining collective purchasing organizations whenever appropriate. In instances when competitive bids are not requested, contract awards must meet a light of day standard (e.g., no conflict of interest, unwarranted favoritism and full disclosure to the Governing Body as the representatives of the community). VII. Admission/Discharge/Transfer No person seeking necessary medical care form the Hospital will be denied such care for reasons other than those based on sound medical practice. No person will be denied care based on race, creed, color, religion, gender, sexual preference or ability to pay. No patient will be discharged from the Hospital except when medical criteria support such discharge. Transfer to an alternate facility may be arranged at the request of the patient/family when the patient is medically stable or if the Hospital is unable to provide the necessary medical care. All transfers must comply with federal statutes regulating transfer of patients. VIII. Conflict of Interest Hospital policy requires the disclosure of potential conflicts of interest so that appropriate steps may be taken to ensure that such conflicts do not inappropriately influence important decisions. Board members, Administration and Hospital employees may not realize any profit or gain as a result of their position with the Hospital apart from the Hospital s compensation and benefits Organizational / Professional Ethics Physician Certification and Agreement of Compliance Page 2 of 4
12 program. A conflict of interest exists when personal interests influence business decisions that are required by one s position, pose a detriment to the interest of the Hospital or result in an improper or illegal gain. Annual conflict of interest disclosure will be required for Board Members, Hospital management and others designated by the Hospital. IX. Payment for Patient Referrals; Prohibited Arrangements with Physicians Employees may not solicit, receive or offer to pay remuneration of any type for referring or recommending the referral of an individual to another person, hospital or medical facility for services. Employees may not solicit, receive or offer to pay remuneration of any type in return for the purchase of goods or services to be paid for by Medicare or Medicaid. Employees may not offer any benefit to a referring physician or other referral source in exchange for referrals or agreements to refer patients to the hospital. All agreements involving compensation or cross-referral with a physician or other referral source must be in writing and reviewed by the Hospital s Legal Counsel. X. Waste Disposal Ohio Valley General Hospital is committed to the safe and responsible disposal of biomedical and other waste products. The Hospital complies with the Clean Air Act, the Clean Water Act, the Resource Conservation and Recovery Act, and other federal and state laws and regulations governing discharge of Hospital waste or hazardous materials. Spills and releases will be reported immediately so that the appropriate clean-up procedures can be initiated. XI. Controlled Substance Hospital policy limits access to controlled substances to properly licensed health care practitioners with express authority to handle them. No health care practitioners may dispense controlled substances except in conformity with state and federal laws and the terms of their licensure. Unauthorized manufacture, distribution, use or possession of controlled substances by Hospital employees is strictly prohibited and will be prosecuted to the fullest extent of the law. XII. Discrimination Ohio Valley General Hospital and its affiliates are committed to an environment of equal opportunity for all qualified applicants and employees without regard to race, color, gender, religion, age, national origin, ancestry, disability or sexual orientation. XIII. Fund Raising The Hospital conducts fund raising activities through its foundation, Pittsburgh s Ohio Valley General Hospital Foundation (the Foundation). Hospital and Foundation policies require that all solicitation of charitable contributions for the Hospital or its affiliates be done under the supervision of the Foundation. The Hospital does not authorize employees or other individuals to use the Hospital s name in any fund-raising activity that is not approved or supervised by the Foundation. Organizational / Professional Ethics Physician Certification and Agreement of Compliance Page 3 of 4
13 XIV. Response to Investigations State and federal agencies have broad legal authority to investigate the Hospital and review its records. The Hospital will comply with subpoenas and cooperate with governmental investigations to the fullest extent required by law. Investigative demands, subpoenas or search warrant involving the Hospital, an employee or a professional staff member should be brought immediately to the compliance officer. The release of any documentation (original or copy) without authorization by the compliance officer or Hospital Legal Council is prohibited. The compliance officer is responsible for coordinating the Hospital s response to investigations and the release of information. X. Reporting Suspected Ethics Policy Violations Any employee or independent professional who believes that someone in the organization has violated the Hospital s organizational ethics policy should contact the Hospital s compliance officer or the Hospital s independent Ethics Hotline service at 1 (888) All reported violations will be investigated by the Hospitals Compliance Officer and will be handled in strict confidence. Employees and independent professionals are not subject to disciplinary action for reporting violations of the Hospital s organizational and professional ethics policy, however failure to report violations will result in disciplinary action. PHYSICIAN CERTIFICATION AND AGREEMENT OF COMPLIANCE I certify that I have read Ohio Valley General Hospital s Organizational/Professional Ethics Policy and fully understand the necessary requirements to maintain the principles established in the policy. I agree specifically to act in accordance with the principles of Ohio Valley General Hospital set forth in that policy and understand that I will be subject to disciplinary action for violating this policy or failing to report violations of this policy. Signed: Print Name: Date: Organizational / Professional Ethics Physician Certification and Agreement of Compliance Page 4 of 4
14 NOTICE TO PHYSICIANS MEDICARE PAYMENT TO HOSPITALS IS BASED IN PART ON EACH PATIENT S PRINCIPAL AND SECONDARY DIAGNOSIS AND THE MAJOR PROCEDURES PERFORMED ON THE PATIENT, AS ATTESTED TO BY THE PATIENT S ATTENDING PHYSICIAN BY VIRTUE OF HIS OR HER SIGNATURE IN THE MEDICAL RECORD. ANYONE WHO MISREPRESENTS, FALSIFIES, OR CONCEALS ESSENTIAL INFORMATION REQUIRED FOR PAYMENT OF FEDERAL FUNDS, MAY BE SUBJECT TO FINE, IMPRISONMENT OR CIVIL PENALTY UNDER APPLICABLE FEDERAL LAWS. _ PHYSICIAN S SIGNATURE _ DATE
15 PHYSICIAN SIGNATURE SAMPLE PLEASE SIGN WITHIN THE BOX (please print name) _ Date