TEMPLE UNIVERSITY HOSPITAL

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1 u TEMPLE UNIVERSITY HOSPITAL INSTRUCTIONS FOR APPLYING FOR EMERGENCY TEMPORARY PRIVILEGES FOR NON-APPLICANTS (these privileges are for care of patients during and emergency disaster) ************************************************************************ Practitioners applying for emergency disaster clinical privileges must provide the following items: 0 Current licensure to practice medicine/dentistry/podiatry 0 Current malpractice insurance coverage 0 Current PPD 0 Documentation and/or contact information of current hospital medical/allied health staff privileges And one of the following 0 Current picture ID issued by a state, federal or regulatory agency 0 Current identification of granted authority from federal, state or municipal entity 0 Current identification of membership of a Disaster Medical Assistance Team (DMA T) ************************************************************************

2 TEMPLE UNIVERSITY HOSPITAL EMERGENCY PRIVILEGES APPLICATION FORM -NON-APPLICANTS PRACTITIONER'S INFORMATION Practitioner's Full Name & Title Specialty: Practice Address: City/State/Zip: Telephone: Home Address: City/State/Zip: Telephone: Date of Birth: Social Security #: Citizenship: If not US citizen, please indicate your visa status at the present time: LICENSURE/CERTIFICATION/LIABILITY PA License # DEA#: Professional Liability Insurance: Board Certification: UPIN #: NPI#: Do you have any of the following: (PALS, ACLS, ATLS, BLS, CPR, NALS, ETC) IF Yes, please list IF No, put N/A Name of Hospital: PRIMARY HOSPITAL AFFILIATION Address of Hospital Telephone: City/State/Zip: Contact Name& Title: Clinical Specialty/Subspecialty: Date of Affiliation: Department:

3 CONFIDENTIAL QUESTIONS PLEASE ANSWER EACH OF THE FOLLOWING QUESTIONS IN FULL IF THE ANSWER TO ANY QUESTION IS 'YES', PLEASE PROVIDE A FULL EXPLANATION OF THE DETAILS IN THE SPACE PROVIDED: Has any disciplinary actions or investigations been initiated or are any pending against you by any State licensure board? Yes No Has your license to practice in any State ever been voluntarily or involuntarily relinquished, denied, limited, suspended or revoked? Yes No Have you ever been suspended, sanctioned, or otherwise restricted trom participating in any private, federal or state health insurance program (eg Medicare/Medicaid)? Yes No Have you ever been subject to an investigation by any private, federal or state agency concerning your participation in any private, federal or state health insurance program? Yes No Has your narcotics registration certificate ever been voluntarily or involuntarily relinquished, denied, limited, suspended or revoked? Yes No Is your narcotics registration certificate currently being challenged? Yes No Have you ever been named as a defendant in any criminal proceeding? Yes No Are you currently board certified? Yes No Has your employment, medical staff appointment or privileges ever been voluntarily or Involuntarily relinquished, suspended, diminished, revoked, refused or limited in any hospital or other health care facility? Yes No Have you ever withdmwn your application for appointment, reappointment and/or clinical privileges or resigned from the medical staff before a decision by a hospital's or health care facilityis governing board? Yes No Have you ever been the subject of disciplinary proceedings or investigations at any hospital or health care facility? Yes No Has your professional liability insurance coverage ever been terminated by action of the insurance company? Yes No Has your present liability insurance carrier excluded any specific area of practice tram your coverage? Yes No If yes, list the area of practice which has been excluded: Have you ever been denied professional liability insurance coverage? Yes No Have any professional liability suits ever been filed against you? Yes No Have any professional liability suits been filed against you which are presently pending? Yes No Have any judgments or settlements been made against you in professional liability cases? Yes No

4 IF YOU HAVE ANSWERED YES TO ANY OF THE QUESTIONS, PLEASE PROVIDE EXPLANATION ********************************************************************************************* ATTESTATION: I hereby attest that I have no condition that would compromise my ability to perform any of the mental or physical functions related to the specific emergency clinical privileges I am requesting Signature Date ********************************************************************************************* AFFIRMATION: I represent that information provided within or attached to this application is accurate and complete lunderstand that as a condition of this application is that any misrepresentation, misstatement, or omission from this application, whether intentional or not is cause for automatic and immediate rejection ofthis application and clinic~lprivileges I further understand that if! have delegated the responsibility for completion of this application, I assume fun responsibility for it's completeness and accuracy Signature Date

5 APPLICANT'S CONSENT/RELEASE/ACKNOWLEDGEMENT As an applicant for limited emergency temporary privileges, I understand that I am not applying for medical staff membership I further understand that it is my responsibility to produce adequate information so that Temple University Hospital can perform a proper evaluation I certify that the information provided is complete, true and correct to the best of my knowledge I fully understand that any misstatement or omission from this application constitutes cause for denial of requested privileges I agree to provide the hospital with any additional information that the hospital or one of its authorized agents may request Failure to produce any requested information will prevent my request for emergency temporary privileges from being processed By applying for limited emergency temporary privileges, I understand that privileges are granted for a defined time to enable care of specific patients If granted limited emergency temporary privileges, I understand they will automatically terminate at the end of the designated timer period; however, may be terminated at any time by the Chief Executive Officer, in consultation with the Department Chair I attest that I am capable, physically and mentally and in all other ways of performing the clinical privileges which I am requesting I hereby authorize representatives of Temple University Hospital to consult associates or others who may have information bearing on my qualifications and consent to inspection of records and documents which may be significant to the evaluation of my qualifications I extend absolute immunity to and release from any liability Temple University Hospital, its authorized representatives, and any third parties, as defined below, for any actions, recommendations, reports, statements, communications or disclosures involving me and related but not limited to the following: Applications for appointment for clinical privileges, including temporary privileges Periodic reappraisals undertaken for reappointment or for change in clinical privileges Proceedings for suspension or reduction of clinical privileges, denial or revocation of appointment or other disciplinary action Summary suspensions Hearing and appellate reviews Hospital and medical staff quality assessment/improvement activities Utilization of hospital services Hospital, medical staff, department, service or committee activities Matters or inquiries concerning professional qualifications, credentials, clinical competence, character, ability to perform the privilege(s) requested and any other matter that might directly or indirectly have any effect on my competence, patient care, or on the orderly operation of this or any other hospital or healthcare facility Applicant Print or Type Name Date Applicant's Signature

6 ADMINISTRATION STATEMENT I have reviewed the Emergency Temporary Clinical Privileges Application Form and other relevant information and based upon my review, I am of the opinion that: The applicant's education, training and experience are adequate and he/she possesses the requisite qualifications for emergency temporary clinical privileges requested with the following exceptions/limitations (If none, please write "NONE", iflimitations or exceptions, list reasons for same): The applicant's education, training and experience are inadequate and therefore he/she does not possess the requisite qualifications for temporary clinical privileges in question The specific inadequacies are: Temporary Clinical Privileges granted: Yes No Medical Staff President/Department Chair Printed Name Date Medical Staff President/Department Chair Signature

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