HCA MIDWEST HEALTH SYSTEM DIVISION PRE-REQUEST FOR CONSIDERATION FORM

Transcription

1 HCA MIDWEST HEALTH SYSTEM DIVISION PRE-REQUEST FOR CONSIDERATION FORM We have received information that you would like to apply for Request for Consideration (RFC) at an HCA Midwest Division facility. Please complete this form and send as indicated below. Fields marked with an asterisk must be completed. HCAPS?(Employed with HCA Physician Services) Yes No Employed or Contracted Start Date *Name *Degree (e.g. MD, DO, DPM, CRNA) *Group Practice Name *Provider Addr. *DOB: *SS#: *NPI: *Home Address: Phone: ( ) Street Address Apt # City, State Zip *Credentialing Address: Phone: ( ) Fax: ( ) Street Address Ste # City, State Zip *Primary Address: Phone: ( ) Fax: ( ) Street Address Ste # City, State Zip * If the same as credentialing address check here ** Please note primary address type is used for our website directory.* *Board Certification: Are you board certified? Yes No If yes, what specialty (ies) If no, do you meet the requirements for Board Eligibility as set by your specialty board? Yes No Date of scheduled exam or, Date of Completion of Formal training *If you are currently in Residency or Fellowship Date of Completion Specialty I hereby make a Request for Consideration for membership on the Medical Staff to practice at the following HCA Midwest Division facility(s) as noted on the attached document. Furthermore, I also make Request for Consideration for the privileges checked as indicated on the attached document. *Physician / Professional Signature (Or Delegate) Date (If using a delegate please print, complete and fax back with the pre-app the Provider s Authorization for Delegate form) Upon receipt of this information, the Nashville Credentialing Processing Center (CPC) will send a RFC Packet to the address you indicated above. This form will also be faxed to the Facility (ies) that you indicated and they will send to you their Facility-Specific Document Packet. Please or fax all Six pages of this completed form to: HCA Midwest Division Phone: (816) * FAX ALL 6 PAGES TO THE DIVISION OFFICE or TO MWDO.PRERFC@HCAHEALTHCARE.COM * * Primary fax (816) Alternate fax (816) * For Internal Use Only: HMCC Associate Provider Approved By: Revised 12/1/2015 Page 1 of 5

2 Kansas Hospital Requests *1. Do you hold an active Kansas state license? Yes No *2. Do you hold a current DEA for the State of Kansas? Yes No If yes, what is the number? If yes, what is the number? If no, have you applied for one? Yes- Date No If no, have you applied for one? Yes- Date No *3. Do you have malpractice insurance and does it include the Kansas Stabilization Fund limits? Yes No If no, have you applied? Yes No Kansas Privilege Lists Physicians ALLEN COUNTY REGIONAL MENORAH MEDICAL OVERLAND PARK REGIONAL HOSPITAL MEDICAL Contact Mgt. ER Family Hospitalist- Other Clinician/Clinical Nurse Specialist/Nurse APP-Neonatal Nurse APP-Physician Asst. APP-Psychology APP-CNM ER (ER &Trauma Priv.) Hospitalist - Other /Onc. Teleradiology Trauma APP-CNM APP-Neonatal Nurse APP-Physician Asst. Medical APP-Physician Asst. - Surgical Psychologist Cardiovasc. General General Oral Plastic Thoracic Vascular Orthopaedic / / Radiation Therapy Radiation Oncology Physiatry Perinatology Gyn Oncology Cardio/Thoracic Colon-Rectal General Oral Plastic Vascular Revised 12/1/2015 Page 2 of 5

3 Kansas Privilege Lists Physicians MID AMERICA SURGERY INSTITUTE 5525 W 119 th St Overland Park, KS APP-Physician Asst. APP- Nurse OVERLAND PARK SURGERY Quivira Rd Ste 100 Overland Park, KS APP-Physician Asst SURGI OF JOHNSON COUNTY 8800 Ballentine Overland Park, KS APP-Physician Asst HEART OF AMERICA SURGERY 8935 State Ave Kansas City, KS (913) Pediatric /Oral General Laser Plastic and Oral General Laser Plastic General & Pediatric General Oral & Maxillary Plastic & Reconstructive Podiatric ENT General GYN Plastic Podiatric Pulmonary *Please note all fields marked with an asterisk must be completed and all five pages returned.* *Also if using a delegate you must submit the Provider Authorization for Delegate form.* Revised 12/1/2015 Page 3 of 5

4 Missouri Hospital Requests *1. Do you hold an active Missouri state license? Yes No *3. Do you hold a current Missouri BNDD? Yes No If yes, what is the number? If yes, what is the number? If no, have you applied for one? Yes- Date No If no, have you applied for one? Yes- Date No *2. Do you hold a current DEA for the State of Missouri? Yes No If yes, what is the number? If no, have you applied for one? Yes Date No Missouri Privilege Lists CASS REGIONAL MEDICAL Aspiration/Biopsy ER Chronic Wound Care & Hyperbaric Metabolic & Endocrine APP Nurse ED APP- Physician Assistant ED APP-Psychologist General POINT AMBULATORY SURGERY APP-Physician Asst. APP NP General Laser Pediatric Dent. Plastic POINT MEDICAL Medical Staff No Priv Anesthesia ER Hospitalist - Other -Newborn Neonatology Perinatology Teleradiology /Immun. Phys Med/Rehab APP APRN/PA APP-APRN/PA-ED APP-CRNA APP-Neonatal Nurse Midwife APP-Pediatric Nurse APP-Psychologist Colon & Rectal General Oral Maxillo Pediatric (Consultation Only) Plastic LAFAYETTE REGIONAL HEALTH ER Telemedicine Teleradiology APP-NP General Plastic Revised 12/1/2015 Page 4 of 5

5 Missouri Privilege Lists LEE S SUMMIT MEDICAL ER Family APP-ANP Hospitalist-FM APP-ANP-ER Hospitalist APP CNM Other APP NNP APP PA APP-PA-ER Tele-radiology BELTON REGIONAL MEDICAL Hospitalist-IM Hospitalist-FM Hospitalist- Other APP-Physician ER Asst. - Hospitalist RESEARCH MEDICAL ER Family Hospitalist Other APP-CNS APP-CRNA Midwife APP-NNP APP-NP APP-NP-ED APP PA APP PA-ED APP-Psychologist SURGI OF KANSAS CITY Surgicenter of Kansas City 701 E 101 st Terr Kansas City, MO (816) APP-NP, PA APP-CRNA Internal Med Neonatology Pulmonary Disease Radiation/Onc. Tele-neurology Bariatric Cardio/Thoracic General Oral/Max. Pediatric Plastic Vascular/Thor. Hematology/Onc Phys Med/Rehab Dent/Gen General Oral Maxillo Facial Plastic /Immun. Infectious Disease Phys Med/Rehab Radiation Oncology General Oral Maxillo Plastic Trauma Anesthesia/ Mgmt General Oral Plastic No Privileges *Please note all fields marked with an asterisk must be completed and all five pages returned.* *Also if using a delegate you must submit the Provider Authorization for Delegate form.* Revised 12/1/2015 Page 5 of 5

6 HCA Credentialing Online - Provider's Authorization for Delegate Step 1 NOTE: Provider must be unique to the provider; it cannot be the same address as a delegate. Step 2 initial and skip to Step 3 name: phone: ( ) - ext. Step 3