APPLICATION FOR ALLIED PROFESSIONAL STAFF

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1 Office of Medical Affairs 736 Irving Ave Syracuse NY Phone: APPLICATION FOR ALLIED PROFESSIONAL STAFF Circle appropriate category CRNA Medical Physicist Research Assistant CST/Dntal Ass t /Ophthl Ass t Nurse Practitioner Respiratory Therapist Licensed Practical Nurse Orthotist / Prosthetist Other Crouse Employed Nurse Physician Assistant Practitioner Registered Nurse 1. PERSONAL INFORMATION: Department of: Last Name First Name Initial Group Name Office Address City State Zip Phone / Fax Home Address City State Zip Phone SS # Birth Have you ever had a name change? Yes No If yes, please list When: DEA Number (If applicable): NPI Number (If applicable): 1

2 2. EDUCATION Phone / s attended Diploma or Name of School Address Fax # From To Degree High School College / Nursing School Graduate School Technical or Business School Additional or Alternative Educational experiences pertinent to your specialty: (Include military and on the job training. Please include address and dates. 3. PROFESSIONAL REFERENCES: (List three individuals in healthcare who can speak to your personal integrity and professional competence. At least one must be a physician or dentist, and at least one must be of your own professional discipline [CRNA, NP, PA]. ) Name: Address: Name: Address: Name: Address: Name: Address: 2

3 4. OCCUPATIONAL HISTORY: List in chronologic order all of the positions you have held with address and date. Use additional paper if needed. Position: Address: Phone: Fax: : Position: Address: Phone: Fax: : Position: Address: Phone: Fax: : 5. LICENSES / REGISTRATIONS / CERTIFICATIONS TO PRACTICE (List all licenses past and present) Type State Registration # Expiration Are you currently certified in your profession? Certifying Body Address 6. PROFESSIONAL SOCIETY MEMBERSHIP 3

4 7. MALPRACTICE INSURANCE (please attach certificate) Insurance Company Phone Policy Number Address Fax Policy Period 8. PREVIOUS MALPRACTICE INSURANCE (Please attach certificate) Insurance Company Phone Policy Number Address Fax Policy Period 9. AFFILIATIONS List all other hospitals or health care facilities with or at which you have had any association, employment, privileges or practice. Use additional sheet of paper if needed. Name: : Address: Phone: Fax: Name: : Address: Phone: Fax: Name: : Address: Phone: Fax: 4

5 10. MISCELLANEOUS INFORMATION Are you now or were you subject to: (provide full details for positive answers on a separate sheet) Yes No 1. previously successful or currently pending limitation, suspension, revocation or voluntary surrender of license or registration to practice in any jurisdiction? 2. previously successful or currently pending limitation, suspension, revocation or voluntary surrender of Drug Enforcement Administration (DEA) registration? 3. limitation, suspension, revocation, denial, non renewal or voluntary surrender of employment, appointment or privileges at any hospital or health care related institution? 4. investigation, corrective action, or discipline by any hospital or health care related institution for any reason, including patient complaints? 5. pending professional malpractice claims or actions, professional conduct proceedings or licensing board actions in any jurisdiction? 6. any judgment, settlement, or findings of malpractice or any finding of professional misconduct in any jurisdiction? 7. suspension, sanction or other restriction in participation in any private, federal or state insurance program (i.e. Medicare)? 8. charges or convictions for sexual harassment, sexual abuse, child abuse, elder abuse, findings pertinent to violations of patient s rights, or other human rights violations? 9. criminal convictions or pending criminal proceedings for felonies or misdemeanors? 10. malpractice premium rating, surcharge, malpractice insurance cancellation, denial or non renewal? 11. any physical or mental impairment (including drugs and / or alcohol) which would prevent you from carrying out the responsibilities of affiliate medical staff membership? 5

6 11. DIRECT SUPERVISOR: _ If more than one physician supervises your practice, please list the names: 12. AFFIRMATION OF INFORMATION The undersigned hereby affirms under the penalties of perjury as follows: that he/she is the applicant named herein; that he/she has read the foregoing application and knows the contents thereof; that the same is complete, true and accurate to his/her own knowledge and belief. Signature of Applicant 13. STATEMENT OF SPONSORING PHYSICIAN / or written practice agreement attached I certify that I am familiar with the qualifications of this applicant and believe him/her to be qualified for appointment to the staff of Crouse Hospital as a member of the Allied Professional Personnel Staff. As the sponsoring physician, I accept the responsibility for the supervision of the professional activities to this individual at Crouse Hospital. Signature of sponsoring / Collaborative Physician Print Name With this application you received a job description outlining general duties performed at Crouse. Please provide a scope of practice approved and signed by your supervisor / collaborative physician. Upon approval, this will be what you re allowed to do at Crouse Hospital. Department Chief Crouse Hospital As Appropriate, Attach Copies of: NYS Licenses & / or Registrations DEA Registration Diplomas Board Certifications NYS Infection Control Certificate Photo ID 6

7 AUTHORIZATION FOR RELEASE OF GENERAL INFORMATION I hereby make application for employment as an Allied Professional at Crouse Hospital hereinafter referred to as Hospital, and request to be allowed to function as described in the job description / scope of practice appropriate to my clinical activity. I fully understand that any significant misstatements in, or omissions from, this application constitute cause for denial of appointment or cause for summary dismissal. If further understand that the Hospital is bound by its Bylaws, the standards of the JCAHO and the New York State Hospital Code. I agree to be bound by such standards and further agree to abide by the terms of the Crouse Employee manual and the NP Practice Agreement. By applying for appointment as an Allied Professional I hereby signify my willingness to appear for interviews in regard to my application and authorize the Hospital, and its representatives to consult with administrators and members of medical staffs of other hospitals or health care facilities with which I have associated and with others, including past and present malpractice insurance carriers, other insurance carriers and organizations who may have information bearing on my professional competence, character and ethical qualifications. I hereby further consent to the inspection by the Hospital, and it representatives of all records and documents, including medical records, at other hospitals, facilities and insurance carriers, 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 liability all employees and representatives of the Hospital for their acts performed in good faith and without malice in connection with evaluating my application and me credentials and qualifications, and I hereby release from my liability any and all individuals and organizations who provide information to the Hospital, 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 hereby further authorize and consent to the release of information by the Hospital to other hospitals, government agencies and medical associations on request regarding any information the Hospital 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 the Hospital and its employees for so doing. All such correspondence shall be available to me. I understand and agree that I, as applicant for an Allied Professional appointment, have the burden of producing adequate information for proper evaluation for my professional competence, character, ethics and other qualifications and for resolving any doubts about such qualifications. I am qualified to carry out the job description associated with this application and will not function in any other capacity. I also understand New York State Law requires me to have a medical history and physical examination as well as documenting my immunity to rubella and rubeola and my PPD status prior to clinical activity at Crouse Hospital. Signature of Applicant Rev. July 18,

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