Mercy Hospital Medical Staff Credentialing Manual

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Mercy Hospital Medical Staff Credentialing Manual"

Transcription

1 CREDENTIALING MANUAL APPROVED BY BYLAWS COMMITTEE MAY 22, 2007 Mercy Hospital Medical Staff Credentialing Manual Approved by the Medical Executive Committee: Mercy Hospital Anderson: January 21, 2008 Mercy Hospital Clermont: January 10, 2008 Mercy Hospital Fairfield: January 15, 2008 Mercy Franciscan - Mt. Airy: January 8, 2008 Mercy Franciscan - Western Hills: January 22, 2008 Approved by the Board of Trustees: January 24, Cred. i -

2 Table of Contents 1. DEFINITIONS AND GENERAL PROVISIONS ADOPTION, AMENDMENT AND APPROVAL APPOINTMENT/REAPPOINTMENT TO THE MEDICAL STAFF FORM AND CONTENT OF APPLICATIONS PROCESSING APPLICATIONS DISASTER PRIVILEGES MONITORING CONNTINUING ELIGIBILITY APPLICATIONS FOR RETURN FROM LEAVE OF ABSENCE TELEMEDICINE CLINICAL PRIVILEGES DEPARTMENT RESPONSIBILITY FOR PRIVILEGES PROCESSING TEMPORARY PRIVILEGES LOCUM TENENS PROCEDURAL SEDATION LOW VOLUME/NO VOLUME PRACTITIONER POLICY CREDENTIALING PLAN FOR ALLIED HEALTH PROFESSIONALS TUBERCULOSIS SCREENING PROGRAM NEW TECHNOLOGIES/NEW PROCEDURES..33 ii

3 CREDENTIALING MANUAL APPROVED BY BYLAWS COMMITTEE MAY 22, DEFINITIONS AND GENERAL PROVISIONS 1.1. Adoption, Amendment and Approval This Credentialing Manual may be adopted or amended by a majority vote of the MEC and is effective upon approval by the Board. 2. APPOINTMENT/REAPPOINTMENT TO THE MEDICAL STAFF 2.1. Form and Content of Applications Initial Applications: All initial applications to the Medical Staff must be in writing and the attestation signed. In the application, the applicant must provide, at a minimum, the following information or documents: Specific requests for Medical Staff category and Clinical Privileges desired; Residence and office locations; Information reflecting completion of medical school or other professional schools appropriate to the applicant s discipline; Declaration page of current professional liability policy (and attached pages as necessary) showing applicant s name, insurer s name, amount of coverage, policy number and effective and expiration dates; Evidence of satisfactory completion of residency/training programs or other educational curriculum; Evidence of specialty board status, if any; Relevant experience in support of the Privileges sought (to be described on Privileges request form(s)); Other facilities where the applicant has or did have Privileges; The CCO will receive peer references as described in Bylaws as well as the Credentialing Manual ; Information about each pending or final disciplinary or licensure action at any other hospital, health maintenance organization, health care entity or academic institution; - Cred. 1 -

4 Information about each voluntary and involuntary withdrawal from a medical staff or a voluntary or involuntary withdrawal of an application for a medical staff appointment or Clinical Privileges; at any other hospital, health maintenance organization, health care entity or academic institution; Information about each pending or final suspension, revocation or restriction, or the voluntary or involuntary relinquishment of an applicant s: license to practice in any state; specialty board certification; state or federal narcotics registration certificate; ability to participate in any Federal Health Program; All professional malpractice claim information relative to the applicant within the last ten (10) years Information about health status; Consent to submit to such physical or mental examination as the MEC may require. Taking or passing a physical or mental examination must not be a part of the application process, but the exercise of Clinical Privileges that are otherwise granted may be made subject to the successful completion of such an examination. The identity of the examining physician(s) must be by mutual consent. In the event of a disagreement concerning the need for an examination or the identity of the examining physician(s), the matter must be referred to the Board, whose decision on the matter is final; Consent to release of information from, and releases from liability in favor of, insurance carriers, references, all institutions where applicant has worked, trained or practiced and to which he has applied and all other sources of information required in the application, and consent to appear for an interview, if requested; Statement acknowledging and understanding Mercy Confidentiality policy; A Medicare fraud attestation; The initial applicant shall submit four (4) passport size photographs which will be attached to the release executed by the applicant and distributed to references to confirm the applicant s identity; 2

5 Verification that the applicant has received and reviewed the Bylaws, Rules and Regulations and all policies of the Medical Staff and of the Hospital relating to appointment to the Medical Staff and the delineation of Clinical Privileges and that he agrees to be bound by them; A non-refundable application fee Statement of Physician Expectations whereby the practitioner attests to having read and agrees to abide by the Expectations Mercy Health supplemental forms, attestation, release and other related documents Applications for Reappointment: At least six months prior to the expiration of a Member s Medical Staff appointment, the CCO will send the Member a written reappointment form. The applicant must provide in his reapplication, at a minimum, the following information or documents: Verification that all information provided on previous applications remains correct, or updated information as necessary. The form must specifically seek, at a minimum, previously undisclosed information relating to: previously successful or currently pending challenges to any licensure or registration or the voluntary relinquishment of such licensure or registration; voluntary or involuntary termination of medical staff membership or voluntary or involuntary limitation, reduction or loss of clinical privileges at another hospital; Any evidence of an unusual pattern of an excessive number of professional liability actions resulting in a final judgment against the applicant; involvement in each professional liability action, including all judgments and settlements within the past ten (10) years relevant practitioner-specific data are compared to aggregate data, when available; Performance Measurement Data including morbidity and mortality data when available; and Information about health status, Specific request for delineated Privileges, Sufficient clinical performance information to grant, limit or deny the requested privileges. 3

6 Applications to Modify Status or Privileges: A Member may apply in writing for a change in his Medical Staff category, Department assignment or Clinical Privileges. Such an application must be in writing Effect of Applications (Initial and Reappointment): Each person who signs the consent and release and submits an application under this Article: Warrants that the information submitted with the application and on all prior applications, as amended, is complete and accurate; agrees that he will provide updated information as soon as practicable concerning each change to a response to any question on an application; and agrees that material misstatements, omissions or misleading statements may be grounds for suspension or termination without a hearing under the Fair Hearing Plan; Consents to appear for such interviews and provide such additional information or documents as any Professional Review Body may require; Authorizes each Professional Review Body to consult with persons who may have information bearing on the applicant s qualifications; Consents to the inspection of all documents and the release of all information that any Professional Review Body may determine to be relevant in assessing the applicant s qualifications, including all records and documents pertaining to his or her licensure, specific training, experience, current competence and ability to perform the privileges requested; Agrees to submit any reasonable evidence of current ability to perform the privileges requested and to submit to such physical or mental examination as the MEC may require. Taking or passing a physical or mental examination must not be a part of the application process, but the exercise of Clinical Privileges that are otherwise granted may be made subject to the successful completion of such an examination. The identity of the examining physician(s) must be by mutual consent. In the event of a disagreement concerning the need for an examination or the identity of the examining physician(s), the matter must be referred to the Board, whose decision on the matter is final Releases all Mercy Representatives, each Professional Review Body and its individual members from liability for acts performed in connection with the evaluation of the applicant s qualifications; Releases all persons from liability who provide information, including information that is otherwise privileged or confidential, in connection with the evaluation of the applicant s qualifications; 4

7 Authorizes Mercy Representatives to release information pertaining to the applicant s qualifications to other hospitals, health care entities and authorized health care licensing, data collection and reporting agencies, to the extent to which consented in writing or permitted or required by law, and releases the Hospital Representatives for so doing; Acknowledges that he has received a copy of the Bylaws, Rules and Regulations and all policies of the Medical Staff and of the Hospital relating to appointment to the Medical Staff and the delineation of Clinical Privileges (and all revisions to those documents), and that he understands them and agrees to be bound by them; Agrees to perform and abide by the obligations set forth under Responsibilities of Medical Staff Membership in the Bylaws, including the obligation to provide continuous care for his or her patients; Agrees to comply with all state and federal laws regarding the practice of medicine, including without limitation, the prohibitions against fee splitting, antireferral and antikickback statutes; Agrees that in the event any Professional Review Body takes, recommends or considers the taking or recommending of a Professional Review Action, he will exhaust all steps provided in these Bylaws, including the provisions of the Resolving Professional Competence, Conduct or Discipline Issues Article and the Fair Hearing Plan as his exclusive remedy Processing Applications CCO General Function: The CCO will perform the following functions respecting all applications for Medical Staff membership or Clinical Privileges at each Mercy Hospital or affiliate Collect and organize all applications and associated materials; Conduct all necessary primary source and other verifications; Serve as repository of credentialing information; Provide Practitioner-specific credentialing information to each Mercy Hospital or affiliate where a Practitioner applies for or holds Medical Staff membership, Clinical Privileges. 5

8 Confidentiality Safeguards: The CCO must establish and enforce appropriate safeguards to ensure that credentialing information Is protected from disclosure to persons or organizations other than Mercy Hospitals or affiliate, except upon a written, dated release signed by the Practitioner and directed specifically to Mercy Health Partners (MHP) authorizing such disclosure; Is provided only to persons at such Hospitals, affiliates involved in pursuit of a legitimate credentialing function; and Is provided with the express caution that such information is confidential and may not be further disclosed Incomplete Applications: The duty to file a complete, signed application, rests exclusively with the applicant. Efforts by the CCO or others to assist in the collection of documents or information do not shift the responsibility from the applicant in any respect. The rules related to timely submission of applications contained in the System-wide Credentialing Services Operations Manual will be strictly enforced: Initial Applicants: Initial applicants who file an incomplete application will receive a letter from the CCO requesting completion within a stated deadline. If the applicant does not comply within the deadline it is deemed voluntarily withdrawn as of that date. The applicant may reapply by submitting a new application and an additional nonrefundable processing fee Applicants for Reappointment: Applicants who fail to return a completed application for reappointment within timeframes approved in the System-wide Credentialing Services Operations Manual will receive a letter from the CCO requesting completion. If the application is not submitted or remains incomplete the application will be deemed voluntarily withdrawn at the end of the current appointment CCO Handling: All applications must be mailed or delivered to the CCO. When an applicant has properly filled in and signed his application, the CCO will do the following: For initial and applicants for reappointment Verify the applicant s current licensure, specific training, experience and current competence through primary sources. Action on an initial application may not proceed until all this information has been collected and verified; 6

9 Query the National Practitioner Data Bank; Obtain professional malpractice claim information; Assure the presence of completed references and all other required forms and consents; Verify the status of privileges at other health care facilities; Check for sanctions through the Office of the Inspector General and the Excluded Provider List System; Collection of statistical data to grant, limit or deny the requested privileges Assure the presence of one peer reference and one hospital verification, if required; (reappointment only) Peer References: Recommendations from peers are obtained and evaluated for all new applicants for privileges. Upon renewal of privileges (reappointment), when insufficient practitioner-specific data are available, the medical staff obtains and evaluates peer recommendations. A recommendation from peers is defined as an appropriate practitioner in the same professional discipline as the applicant who has personal knowledge of the applicant and the applicant s ability to practice. They reflect a basis for recommending the granting of privileges. Sources for peer recommendation may include the following: An organization performance improvement committee, the majority of whose members are the applicant s peers; A reference letter(s), written documentation or documented telephone conversation(s) about the applicant from a peer(s) who is knowledgeable about the applicant s professional performance and competence; A department or major clinical service chairperson who is a peer; The Medical Executive Committee Peer recommendations include the following: Relevant training and experience Current competence Any effects of health status on privileges being requested 7

10 Patient Care Medical/clinical Knowledge Technical and clinical skills Clinical judgment Practice-Based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-Based Practice Forwarding the Application File: When all information has been collected and sources have been verified as necessary, the CCO will forward credentialing information to the Hospital(s) to which the applicant has applied for Membership and Privileges Each Hospital to which the applicant has applied for Membership and Privileges will assure the assembly of the following information: performance data (i.e., clinical activity data), information and comparative physician profiles to include at a minimum, the following information: review of operative and other clinical procedure(s) performed and their outcomes pattern of blood and pharmaceutical usage requests for tests and procedures length of stay patterns morbidity and mortality data practitioner s use of consultants other relevant criteria as determined by the individual MHP organized medical staffs Department Recommendations: The Chairperson of the Department (or his designee) in which the applicant seeks Privileges must review the Application File. He may conduct an interview and must document the interview if he conducts one. The Chairperson may make such additional inquiries, as he deems appropriate in assessing the applicant s qualifications. He should also coordinate his review with that of other chairpersons in whose Departments the applicant also seeks Privileges. Upon completion 8

11 of the review, interview and inquiry, the Chairperson must make a written recommendation to the Credentials Committee relating to the requested status and Clinical Privileges. The interview, if one is conducted, is not a hearing, and neither the interview nor the recommendation entitles the applicant to any rights under the Fair Hearing Plan. Where the applicant is a Department Chairperson, the report will be prepared by the Credentials Committee Credentials Committee Action: The Credentials Committee must review the Application File, Department and peer recommendation(s). The Credentials Committee must collect and consider available information concerning the applicant s professional conduct, performance and conduct both in the Hospital and at other health care entities. The Credentials Committee may conduct an interview and must make a record of the interview and include the record in the Application File. At the conclusion of its review, the Credentials Committee must make a recommendation to the MEC pertaining to the requested Medical Staff status, staff category, Department assignment and Clinical Privileges, with suggested special conditions or limitations, if any MEC Action: At its next regular meeting after receipt of the Credentials Committee report and recommendation, or as soon thereafter as is practical, the MEC shall consider the Credentials Committee report and any other relevant information. The MEC may request additional information, return the matter to the Credentials Committee for further investigation, and/or elect to interview the applicant. The MEC shall then prepare and forward to the Chief of Staff, for prompt transmittal to the Board, a recommendation as to Medical Staff appointment and, if appointment is recommended, as to membership category, Clinical Privileges to be granted and any special conditions to be attached to the appointment If the recommendation Affects Adversely the applicant s membership or Clinical Privileges, the MEC must give Notice to the applicant of his right to a hearing in accordance with the Fair Hearing Plan Board Action: The Board must review each favorable recommendation of the MEC requesting Medical Staff appointment and Clinical Privileges. SUBCOMMITTEE OF THE BOARD: In lieu of review by the full Board, the Board may, pursuant to authority in the Board s bylaws, direct that initial and reappointment applications which meet the criteria for expedited credentialing and privileging process, and have received approval by the Department Chair, Credentials Committee and Medical Executive Committee may be reviewed by a Board subcommittee of at least two voting members of the governing body Only those applicants that qualify under Medical Staff Standard 4.35 of the Comprehensive Accreditation Manual for Hospitals published by the Joint Commission may be reviewed. Approval of such applicants is effective as of the date of approval by the designated subcommittee. An application which has been deemed complete and has received approval by the Department Chair, Credentials Committee and the Medical Executive Committee shall be forwarded to the Board Committee of two or more persons. The Medical staff uses criteria developed for the expedited process when recommending privileges. The following situations are evaluated on a case by case basis and usually are ineligible for Board Subcommittee approval if any of the following has occurred: 9

12 Submission of an incomplete application; Recommendation from the Credentials or Medical Executive Committee that is adverse or with limitation A current challenge or a previous successful challenge to licensure or registration Involuntary termination of medical staff membership at another organization Involuntary limitation, reduction, denial or loss of clinical privileges; or, The hospital determines that there has been either an unusual pattern of, or an excessive number of, professional liability actions resulting in a final judgment against the applicant. FULL BOARD: The actions of the Governing Board Subcommittee will be reported to the full Board at their next regular scheduled meeting If the Board (or designated subcommittee) accepts the recommendation, its decision is final. The applicant will be promptly notified of his department assignment, staff category, clinical privileges and any special conditions If the full Board rejects a recommendation, and its decision Affects Adversely the applicant s membership or Clinical Privileges, it must direct the Chief Executive Officer to give prompt Notice to the applicant of his right to a hearing in accordance with the Fair Hearing Plan If a designated committee of the board rejects the recommendation, the committee must refer it back to the MEC for further consideration. 2,2.13 Time for Processing of Applications: Initial Applications: The application process must be completed within a reasonable time. The CCO should collect and verify information within 41 days of the applicant s delivery of the application. The Department Chairperson should prepare and deliver his or her report to the Credentials Committee at its next regular meeting. The Credentials Committee, MEC (except as may be necessary for JRC review) and the Board, in turn, should each act on an application at the next regular meeting following receipt of the preceding recommendation. Complete applications (as defined in the Credentialing Manual) should normally be processed within 90 days, 10

13 2.3 DISASTER PRIVLEGES: unless the gathering of additional information or additional deliberation in specific cases is necessary to ensure a fully informed review. These time limits are guidelines only and do not create any right to have an application processed within a particular time Reappointment applications: Will be mailed out to the applicants six months prior to the earliest entity expiration date. Reappointment applications will be processed by the CCO within 41 days and submitted to the sites where they will be processed based upon the earliest entity expiration date Records: A separate record is maintained for each individual requesting Medical Staff Membership or Clinical Privileges. These records are confidential peer review information subject to the protection of Ohio law and these Bylaws, and must be stored under appropriate security measures. The organization may grant disaster privileges to volunteers eligible to be licensed independent practitioners when the Chief Executive Officer or his designee has implemented the Hospital s Emergency Management Plan, and has determined that additional medical personnel are needed in order to address the emergency. Medical Personnel who are not currently members of the Medical Staff request or are requested by the Hospital to provide patient care during the emergency; The Medical Personnel requesting these privileges present to the Chief Executive Officer, or the Chief of Staff or their designees, a valid government-issued photo identification issued by a state or federal agency (e.g., drivers license or passport) and at least one of the following: A current picture hospital ID card from their primary hospital that clearly identifies professional designation; A current license to practice medicine. Primary source verification of the license. Primary Source verification begins as soon as the immediate situation is under control, and is completed within 72 hours from the time the volunteer practitioner presents to the organization. In the extraordinary circumstance that primary source verification cannot be completed in 72 hours (e.g., no means of communication or a lack of resources), it is expected that it be done as soon as possible. In this extraordinary circumstance, there must be documentation of the following: Why primary source verification could not be performed in the required time frame, evidence of a demonstrated ability to continue to provide adequate care, treatment and services: and an attempt to rectify the situation as soon as possible. Primary source verification of licensure would not be required if the volunteer practitioner has not provided care, treatment and services under the disaster privileges Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT); or Medical Reserve 11

14 Corp. (MRC), Emergency System for Advance Registration of Volunteer Health Care Personnel( ESAR-VHP), or other recognized state or federal organizations or groups; Identification indicating that the individual has been granted authority to render patient care in emergency circumstances, with such authority having been granted by a federal, state or municipal governmental entity; Present Identification by a current hospital or medical staff member with personal knowledge regarding practitioner s identity volunteer s ability to act as a licensed independent practitioner during a disaster; The medical staff oversees the professional practice of volunteer licensed independent practitioners The organization makes a decision (based o information obtained regarding the professional practice of the volunteer) within 72 hours related to the continuation of the disaster privileges initially granted The verification of information in accordance with the Medical Staff Bylaws for membership continues as a high priority during the implementation of the Emergency Management Plan The physicians who are granted Disaster Privileges will report to the Disaster Control Center Chief Medical Officer for direction and management. Upon presentation of any of the information in above, the Chief Executive Officer, or the Chief of Staff or their designees may grant disaster privileges on a case by case basis at his or her discretion. Unless membership is granted pursuant to the Expedited Credentialing Policy, said privileges shall terminate when the Emergency Management Plan implementation is terminated, the immediate situation is under control and the practitioner to whom disaster privileges have been granted has transferred care of patients treated during the emergency to a member of the Medical Staff. Furthermore, the Chief of Staff may terminate these privileges at any time and for any reason during the implementation of the Emergency Management Plan. Said termination shall not be considered a reportable event with the National Practitioner Data Bank. 12

15 MERCY HEALTH PARTNERS DISASTER INFORMATION & RELEASE AUTHORIZATION FORM (WHEN THE EMERGENCY SITUATION NO LONGER EXISTS, THE DISASTER PRIVILEGES WILL BE TERMINATED) APPLICANT S NAME: SPECIALTY: BOARD STATUS: GROUP PRACTICE NAME: OFFICE ADDRESS: Street City State Zip TELEPHONE: ( ) FAX: ( ) RESIDENCE ADDRESS: Street City State Zip TELEPHONE: ( ) FAX: ( ) PRIMARY HOSPITAL NAME: HOSPITAL ADDRESS: Street City State Zip DATE OF BIRTH: SS # MEDICAL LICENSURE #: EXPIRATION: STATE DEA #: EXPIRATION: MALPRACTICE INSURANCE CARRIER: LIABILITY COVERAGE LIMITS EQUAL TO $1M/$3M YES NO Expiration * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 13

16 ADMINISTRATIVE COMPLETION Credentials Presented : Government Issued ID (driver s license or passport) and Hospital ID Badge Government Issued ID (driver s license or passport) and Medical License Government Issued ID (driver s license or passport) and DMAT Identification Government Issued ID (drivers license or passport) and Identification indicating that the individual has been granted authority to render patient care in emergency circumstances, with such authority having been granted by a federal, state or municipal governmental entity Government Issued ID (drivers license or passport) and presents identification by a current hospital or medical staff member with personal knowledge regarding practitioner s identity volunteer s ability to act as a licensed independent practitioner during a disaster; Disaster Privileges Authorized by: Title Mercy Member Assigned to: Location Assigned: Time: * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * MEDICAL STAFF PERSONNEL Credentials Verified by: Title If unable to verify credentials within 72 hours of disaster, please indicate reason below: 14

17 15

18 2.4 Monitoring Continuing Eligibility The CCO will continuously monitor, verify and maintain current information on each Medical Staff Member respecting licensure, narcotics permits, TB Testing documentation as required by the Ohio Department of Health, and professional liability insurance. 2.5 Applications for Return From Leave of Absence A Member whose appointment has not expired and who seeks return from a leave of absence must file a written request to return. At a minimum, the request must contain: A summary of his or her activities during the period of leave; and Details of all medical training and experience and other circumstances during the period of leave demonstrating the maintenance of skills; and Evidence of current licensure, current professional liability insurance, current competence and current ability to perform the privileges requested The MEC may request any additional information it may require to assure that the Member is qualified for Medical Staff membership and possesses current competence to exercise the Clinical Privileges to which he seeks to return The Medical Staff Offices at each entity must conduct a National Practitioner Data Bank query and primary source verification of licensure The MEC must process the request for return from leave, with the assistance and recommendation of the Credentials Committee if desired, applying the same standards as an applicant for reappointment Reinstatement is not effective until approved by the Board Where a Member s appointment expires during the leave of absence, the MEC in its discretion may require a full initial application 2.6 Telemedicine Telemedicine is the use of medical information exchanged from one site to another via electronic communications. The medical staff recommends which clinical services are appropriately delivered by licensed independent practitioners through this medium. The clinical services offered are consistent with commonly accepted quality standards. Mercy facilities are defined as the originating site, where the patient is located at the time the service is provided. 16

19 All licensed independent practitioners who are responsible for the patient s care, treatment and services via telemedicine links are credentialed and privileged to do so at the originating site through one of the following mechanisms: The originating site fully privileges and credentials the practitioner, according to The JC standards The originating site privileges practitioners using credentialing information from the distant site if the distant site is a The JC accredited organization; or The originating site uses the credentialing and privileging decisions from the distant site to make a final privileging decision if all the following requirements are met: The distant site is a The JC accredited hospital or ambulatory care organization; The practitioner is privileged at the distant site for those services to be provided at the originating site; The originating site has evidence of an internal review of the practitioner s performance of these privileges and sends to the distant site information that is useful to assess the practitioner s quality of care, treatment, and services for use in privileging and performance improvement. 3 CLINICAL PRIVILEGES 3.1 Department Responsibility for Privileges Each Department must have a system for the development of delineation criteria, the adjustment of criteria to meet developing community needs and the state of medical knowledge, and the monitoring of delineated Privileges. At a minimum, this system must: Make quality of patient care its main design objective; Establish and revise criteria that include, at a minimum, evidence of current licensure, relevant training or experience, current competence, and ability to perform the Privileges requested; Ensure that quality of care among those with the same Privileges is uniform within Departments and, working with other Department chairpersons and Medical Staff leadership, uniform between Departments and among Medical Staff Members and non-members; Ensure that where categories are used, they are clear and well-defined; 17

20 3.1.5 Include mechanisms for ensuring that those who hold Clinical Privileges remain within their respective delineations; Employ appropriate means of surveillance, including the results of Hospital quality monitoring, to assess the exercise of delineated Privileges; Where new Privileges are sought, privilege criteria are developed by the Department, reviewed by the Credentials Committee and the MEC and approved by the Board before Privileges are granted to particular Practitioners. 3.2 Processing Temporary Privileges Temporary privilege requests will be processed as promptly as possible in a manner consistent with the Bylaws Initial Applicants Awaiting Credentials Committee, MEC or Board Action An applicant is considered for temporary privileges when all primary source verifications have been completed, including, but not limited to, A complete application Current licensure; Relevant training and experience; Current competence and ability to perform the privileges requested; Results of the National Practitioner Data Bank query have been obtained and evaluated; The applicant has in force professional liability insurance as specified by the Board, covering the exercise of the privileges requested; No current or previously successful challenge to licensure or registration No voluntary or involuntary limitation, reduction, loss or suspension of membership or clinical privileges at another organization Once the preceding requirements are met, temporary privileges may be granted for a limited period of time, not to exceed 120 days, by the Chief Executive Officer (or designee) upon recommendation of either the applicable clinical department 18

CREDENTIALING PROCEDURES MANUAL

CREDENTIALING PROCEDURES MANUAL CREDENTIALING PROCEDURES MANUAL Page PART I Appointment Procedures 1 PART II Reappointment Procedures 5 PART III Delineation of Clinical Privileges Procedures 7 PART IV Leave of Absence, Reinstatement,

More information

MEDICAL STAFF POLICY & PROCEDURE

MEDICAL STAFF POLICY & PROCEDURE 240 Maple Street PO Box 470 Woodruff, WI 54568 (715) 356-8000 MEDICAL STAFF POLICY & PROCEDURE NUMBER: MS.4 EFFECTIVE/APPROVAL DATE: TITLE: CREDENTIALING POLICY REVISION DATE: 4/97; 1/98; 7/98; 2/99; 12/00;

More information

TITLE: Allied Health Professional Policy

TITLE: Allied Health Professional Policy TITLE: Allied Health Professional Policy Number: Version: Status: Current Type: Medical Staff Policy Author: Medical Staff Original Date: Revised Dates: Review Cycle: Triennial Deactivation Date: Facility:

More information

EFFECTIVE DATE: 10/04. SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31

EFFECTIVE DATE: 10/04. SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31 SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31 EFFECTIVE DATE: 10/04 Applies to all products administered by the plan except when changed by contract Policy Statement:

More information

Stanford Hospital and Clinics Lucile Packard Children s Hospital

Stanford Hospital and Clinics Lucile Packard Children s Hospital Practitioners Page 1 of 10 I. PURPOSE To outline individuals who are authorized to provide care as an Allied Health professional as well as describe which categories of individuals who will be processed

More information

MGHS CREDENTIALS MANUAL

MGHS CREDENTIALS MANUAL MGHS CREDENTIALS MANUAL POLICY FOR MEMBERSHIP TO THE MARQUETTE GENERAL HEALTH SYSTEM (MGHS) MEDICAL STAFF Applications for Medical Staff membership to MGHS shall be provided to physicians, dentists, podiatrists,

More information

DEFINITIONS: The following definitions will apply to this Policy:

DEFINITIONS: The following definitions will apply to this Policy: CLASSIFICATION: MEDICAL STAFF POLICY NUMBER: MS004 EFFECTIVE DATE: 08/91 SUBJECT: Allied Health Professionals DATE REVIEWED/ REVISED: 03/97, 09/01, 06/03, 12/03, 09/04, 11/08, 2/09, 2/10, 3/12, 2/13, 3/13,

More information

CHRISTUS Santa Rosa HOSPITAL MEDICAL STAFF MEMBERSHIP, CREDENTIALING, PRIVILEGING AND DUE PROCESS MANUAL TABLE OF CONTENTS

CHRISTUS Santa Rosa HOSPITAL MEDICAL STAFF MEMBERSHIP, CREDENTIALING, PRIVILEGING AND DUE PROCESS MANUAL TABLE OF CONTENTS CHRISTUS Santa Rosa HOSPITAL MEDICAL STAFF MEMBERSHIP, CREDENTIALING, PRIVILEGING AND DUE PROCESS MANUAL TABLE OF CONTENTS I. APPOINTMENT AND REAPPOINTMENT PROCEDURE II. PROCEDURES FOR DELINEATING PRIVILEGES

More information

II. INTERDISCIPLINARY PRACTICE COMMITTEE (IPC)

II. INTERDISCIPLINARY PRACTICE COMMITTEE (IPC) Rules and Regulations and Credentialing and Privileging Policy Advanced Practice Professionals and Ancillary Staff Interdisciplinary Practice Committee I. CATEGORIES The Medical Executive Committee (MEC)

More information

MOONLIGHTING INSTRUCTIONS:

MOONLIGHTING INSTRUCTIONS: MOONLIGHTING INSTRUCTIONS: Please Complete and Send the Forms on the Following 6 Pages to the Medical Staff Office at Box URMFG 278911. 1) URMC Moonlighting (extra work shift) Request Form, p. 1 of 6 2)

More information

Nonphysician Practitioner Policy a.k.a. Specified Professional Personnel Policy

Nonphysician Practitioner Policy a.k.a. Specified Professional Personnel Policy RENOWN REGIONAL MEDICAL CENTER Nonphysician Practitioner Policy a.k.a. Specified Professional Personnel Policy (The Term Allied Health Professional will not be used in this policy since in the Renown Regional

More information

Credentials Policy Manual. Reviewed & Approved by MEC 8/13/2012 Reviewed & Approved by Board of Commissioners 9/11/12

Credentials Policy Manual. Reviewed & Approved by MEC 8/13/2012 Reviewed & Approved by Board of Commissioners 9/11/12 Credentials Policy Manual Reviewed & Approved by MEC 8/13/2012 Reviewed & Approved by Board of Commissioners 9/11/12 Credentialing Policy Manual Table of Contents I. Application for Appointment to Staff...1

More information

Surgical Center of Greensboro/Orthopaedic Surgical Center Div of Surgical Care Affiliates

Surgical Center of Greensboro/Orthopaedic Surgical Center Div of Surgical Care Affiliates Allied Health Staff Application Instructions We are pleased to provide you with our Allied Health Staff application packet. Please do not write see attached or see resume or CV on the application. All

More information

ALLIED HEALTH PROFESSIONALS POLICY

ALLIED HEALTH PROFESSIONALS POLICY MEMORIAL HOSPITAL UNIVERSITY OF COLORADO HEALTH MEDICAL, DENTAL AND PODIATRIC STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS ALLIED HEALTH PROFESSIONALS POLICY Approved by the Medical Executive Committee

More information

LOCUM TENENS APPLICATION Page 1 of 4

LOCUM TENENS APPLICATION Page 1 of 4 Page 1 of 4 This form is only valid for Locum Tenens providing coverage for up to 60 days. SECTION I PROVIDER INFORMATION This section to be completed by the PacificSource participating practitioner. Please

More information

UNIVERSITY OF NORTH CAROLINA HOSPITALS

UNIVERSITY OF NORTH CAROLINA HOSPITALS 7 1 BYLAWS OF THE MEDICAL STAFF UNIVERSITY OF NORTH CAROLINA HOSPITALS Approved by the Executive Committee of the Medical Staff, November 5, 2001. Approved by the Medical Staff, December 5, 2001. Approved

More information

POLICY REGARDING ADVANCED PRACTICE NURSES, PHYSICIAN ASSISTANTS AND OTHER CREDENTIALED HEALTH CARE PROVIDERS

POLICY REGARDING ADVANCED PRACTICE NURSES, PHYSICIAN ASSISTANTS AND OTHER CREDENTIALED HEALTH CARE PROVIDERS MEDICAL-DENTAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS OF CHRISTIANA CARE HEALTH SERVICES, INC POLICY REGARDING ADVANCED PRACTICE NURSES, PHYSICIAN ASSISTANTS AND OTHER CREDENTIALED HEALTH CARE

More information

CREDENTIALING POLICY FOR ALLIED HEALTH PROFESSIONALS

CREDENTIALING POLICY FOR ALLIED HEALTH PROFESSIONALS CREDENTIALING POLICY FOR ALLIED HEALTH PROFESSIONALS TABLE OF CONTENTS Article Page 1 DEFINITIONS.. 1 2 SCOPE AND OVERVIEW OF POLICY 2.1 Scope of Policy 3 2.2 Classification of Allied Health Professionals..

More information

APPLICATION FOR ALLIED PROFESSIONAL STAFF

APPLICATION FOR ALLIED PROFESSIONAL STAFF Office of Medical Affairs 736 Irving Ave Syracuse NY 13210 Phone: 315-470-7646 APPLICATION FOR ALLIED PROFESSIONAL STAFF Circle appropriate category CRNA Medical Physicist Research Assistant CST/Dntal

More information

TITLE: Locum Tenens (LT) Policy

TITLE: Locum Tenens (LT) Policy TITLE: Locum Tenens (LT) Policy Effective Date: 2/2014 Locum Tenens (LT) practitioners are defined as those who temporarily fulfill the duties of another. Requests for LT must come from a group whose practitioners

More information

Doctors Hospital Allied Health Professional Application for Appointment

Doctors Hospital Allied Health Professional Application for Appointment Doctors Hospital Allied Health Professional Application for Appointment Applying for the following job (please check): Allied Health Delineation of Privileges Allied Health Scope of Practice Category 1

More information

CREDENTIALING POLICY AND PROCEDURES MANUAL OF THE MEDICAL STAFF OF ADVENTIST HINSDALE HOSPITAL AND ADVENTIST LA GRANGE MEMORIAL HOSPITAL

CREDENTIALING POLICY AND PROCEDURES MANUAL OF THE MEDICAL STAFF OF ADVENTIST HINSDALE HOSPITAL AND ADVENTIST LA GRANGE MEMORIAL HOSPITAL CREDENTIALING POLICY AND PROCEDURES MANUAL OF THE MEDICAL STAFF OF ADVENTIST HINSDALE HOSPITAL AND ADVENTIST LA GRANGE MEMORIAL HOSPITAL Approval: Medical Executive Committees: Hinsdale Hospital July 28,

More information

MEDICAL RESOURCE CENTER FOR RANDOLPH COUNTY, INC. POLICY & PROCEDURES

MEDICAL RESOURCE CENTER FOR RANDOLPH COUNTY, INC. POLICY & PROCEDURES NUMBER: PAGE: 1 OF: 12 ADOPTED FROM: NACHC REVIEWED BY: Executive Team, Board of Directors DATES OF REVISION: APPROVED: July 21, 2011 DATES OF REVIEW: July 21, 2011 1. POLICY: This policy applies to all

More information

Initial Credentialing Application: Certified Registered Nurse Anesthetist (CRNA)

Initial Credentialing Application: Certified Registered Nurse Anesthetist (CRNA) Updated 1/1/2013 Specialty Surgery Center Initial Credentialing Application: Certified Registered Nurse Anesthetist (CRNA) Dear Anesthesia Provider, Thank you for your interest in providing services at

More information

PLATTE COUNTY MEMORIAL HOSPITAL MEDICAL STAFF CREDENTIALING POLICY ARTICLE I DEFINITIONS

PLATTE COUNTY MEMORIAL HOSPITAL MEDICAL STAFF CREDENTIALING POLICY ARTICLE I DEFINITIONS PLATTE COUNTY MEMORIAL HOSPITAL MEDICAL STAFF CREDENTIALING POLICY ARTICLE I DEFINITIONS The following definitions shall apply to terms used in this policy: (1) "Board" means the Board of Directors of

More information

Los Angeles County Department of Mental Health Credentialing Application for Prescribing Practitioners Delivering Services to DCFS Children

Los Angeles County Department of Mental Health Credentialing Application for Prescribing Practitioners Delivering Services to DCFS Children Los Angeles County Department of Mental Health Credentialing Application for Prescribing Practitioners Delivering Services to DCFS Children This application is exclusively for prescribing practitioners

More information

POLICY ON CREDENTIALING ALLIED HEALTH PROFESSIONALS MIDLAND MEMORIAL HOSPITAL. Midland, Texas 79701

POLICY ON CREDENTIALING ALLIED HEALTH PROFESSIONALS MIDLAND MEMORIAL HOSPITAL. Midland, Texas 79701 POLICY ON CREDENTIALING ALLIED HEALTH PROFESSIONALS At MIDLAND MEMORIAL HOSPITAL Midland, Texas 79701 Date: April 2004 Revision: October 2009 Policy Tech Ref # : 5833 1 Approved: 02/14/2013 Last Reviewed:

More information

ARTICLE I - DEFINITIONS... 1 ARTICLE II - SCOPE AND OVERVIEW OF POLICY... 2

ARTICLE I - DEFINITIONS... 1 ARTICLE II - SCOPE AND OVERVIEW OF POLICY... 2 PAGE ARTICLE I - DEFINITIONS... 1 ARTICLE II - SCOPE AND OVERVIEW OF POLICY... 2 ARTICLE III - APPLICATION... 3 Section 3.01 - General Qualifications of Applicants... 3 Section 3.02 - No Entitlement to

More information

North Carolina Department of Insurance. Uniform Application. To Participate as a Health Care Practitioner

North Carolina Department of Insurance. Uniform Application. To Participate as a Health Care Practitioner orth Carolina Department of Insurance Uniform Application To Participate as a Health Care Practitioner ote: Please send completed applications directly to the organizations with which you seek to contract.

More information

Standard HR.7 All individuals permitted by law and the organization to practice independently are appointed through a defined process.

Standard HR.7 All individuals permitted by law and the organization to practice independently are appointed through a defined process. Credentialing and Privileging of Licensed Independent Practitioners The following standards apply to individuals permitted by law and the organization to provide patient care services without direction

More information

Your Hearing Network Application and Credentialing Agreement.

Your Hearing Network Application and Credentialing Agreement. Your Hearing Network Application and Credentialing Agreement. Use this checklist to ensure the application you are submitting is complete. Credentialing application: 1. Fully completed application (one

More information

CREDENTIALING POLICY OF UNIVERSITY OF UTAH HOSPITAL AND CLINICS

CREDENTIALING POLICY OF UNIVERSITY OF UTAH HOSPITAL AND CLINICS CREDENTIALING POLICY OF UNIVERSITY OF UTAH HOSPITAL AND CLINICS Revised November, 2004 TABLE OF CONTENTS PAGE 1. DEFINITIONS...1 1.A DEFINITIONS...1 1.B TIME LIMITS...2 1.C DELEGATION OF FUNCTIONS...2

More information

Resident Credentialing Policy Wayne State University

Resident Credentialing Policy Wayne State University Resident Credentialing Policy Wayne State University REQUIREMENTS FOR INITIAL RESIDENT APPOINTMENT Residency Office Responsibilities: 1. Resident Initial Appointment Recommendation Letter: Initial applications

More information

Ratified: June 6, 2013 PROFESSIONAL STAFF BY-LAW

Ratified: June 6, 2013 PROFESSIONAL STAFF BY-LAW Ratified: June 6, 2013 PROFESSIONAL STAFF BY-LAW ARTICLE 1 DEFINITIONS AND INTERPRETATION...4 Section 1.1 Definitions...4 Section 1.2 Interpretation...6 Section 1.3 Delegation of Duties...6 Section 1.4

More information

New Jersey Physician Recredentialing Application (Please type or print)

New Jersey Physician Recredentialing Application (Please type or print) New Jersey Physician Recredentialing Application (Please type or print) All sections must be completed fully or clearly marked as not applicable. No area should be left blank. SECTION 1 Personal Information

More information

Revised July 2014 MEDICAL STAFF BYLAWS OF MINISTRY OUR LADY OF VICTORY HOSPITAL, INC.

Revised July 2014 MEDICAL STAFF BYLAWS OF MINISTRY OUR LADY OF VICTORY HOSPITAL, INC. MEDICAL STAFF BYLAWS OF MINISTRY OUR LADY OF VICTORY HOSPITAL, INC. DEFINITIONS 1. MEDICAL STAFF means all Doctors of Medicine, Doctors of Osteopathy, Doctors of Dentistry and Doctors of Podiatry, who

More information

Allied Health Care Provider: Appointment and Re-appointment

Allied Health Care Provider: Appointment and Re-appointment Allied Health Care Provider: Appointment and Re-appointment Document Owner: Lawson, Louise Version: 8 Effective Date: 10/23/2013 Revision Date: 4/26/2015 Approvers: Calkins, Paul; Del Boccio, Suzanne;

More information

Allied Health Professional Rules and Regulations

Allied Health Professional Rules and Regulations Allied Health Professional Rules and Regulations I. Purpose To maintain an organized Allied Health Professional Staff committed to promoting effective delivery of patient services, and continuous review

More information

TEMPLE UNIVERSITY HOSPITAL

TEMPLE UNIVERSITY HOSPITAL 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) ************************************************************************

More information

Policies of the University of North Texas Health Science Center. Chapter 14 UNT Health. 14.340 Credentialing and Privileging Licensed Practitioners

Policies of the University of North Texas Health Science Center. Chapter 14 UNT Health. 14.340 Credentialing and Privileging Licensed Practitioners Policies of the University of North Texas Health Science Center 14.340 Credentialing and Privileging Licensed Practitioners Chapter 14 UNT Health Policy Statement. UNT Health shall credential and grant

More information

REHAB PROVIDER NETWORK Professional Staff Credentialing Form

REHAB PROVIDER NETWORK Professional Staff Credentialing Form REHAB PROVIDER NETWORK Professional Staff Credentialing Form ***** THERAPIST LICENSE MUST BE ATTACHED TO THIS FORM ***** The information requested on this form is required to certify your status as a licensed

More information

Departmental Policy. Nurse Credentialing and the Nurse Credentialing Committee

Departmental Policy. Nurse Credentialing and the Nurse Credentialing Committee Page 1 of 6 Nurse Credentialing and the POLICY STATEMENT To describe the procedure for credentialing and privileging of Advanced Practice Nurses (APRNs), nurses in expanded roles, and non-hospital employed

More information

Rehab Net of Arkansas. Provider Application

Rehab Net of Arkansas. Provider Application Rehab Net of Arkansas Provider Application Discipline P.T. O.T. S.L.P. (1) Business Name Physical Address FACILITY DATA Phone Fax (2) Billing Address Phone Fax (3) Mailing Address (4) Owner/Contact Person

More information

Dental Initial Credentialing Application

Dental Initial Credentialing Application Dental Initial Credentialing Application Practitioner and Practice Information Name(last) (First) (Middle) Degree Social Security Number Personal NPI Date of Birth Gender Practice Name Practice Taxpayer

More information

Medical Staff Services. Dear Applicant,

Medical Staff Services. Dear Applicant, Dear Applicant, Thank you for your interest in seeking appointment to the Medical or Allied Health Professional (AHP) Staff of MedStar Montgomery Medical Center. All initial appointments to the Medical

More information

UNIVERSITY OF MARYLAND MEDICAL CENTER MEDICAL STAFF BYLAWS

UNIVERSITY OF MARYLAND MEDICAL CENTER MEDICAL STAFF BYLAWS UNIVERSITY OF MARYLAND MEDICAL CENTER MEDICAL STAFF BYLAWS TABLE OF CONTENTS DEFINITIONS. 1 ARTICLE 1. NAME & MISSION. 3 ARTICLE 2. PURPOSE AND AUTHORITY.. 4 ARTICLE 3. MEMBERSHIP 6 ARTICLE 4. CATEGORIES

More information

BYLAWS OF NORTHWEST HOSPITAL MEDICAL STAFF

BYLAWS OF NORTHWEST HOSPITAL MEDICAL STAFF NORTHWEST HOSPITAL & MEDICAL CENTER Seattle, Washington BYLAWS OF NORTHWEST HOSPITAL MEDICAL STAFF Effective Date: October 19, 2012 BYLAWS OF NORTHWEST HOSPITAL MEDICAL STAFF TABLE OF CONTENTS PAGE ARTICLE

More information

ALLIED HEALTH PROFESSIONAL POLICIES AND PROCEDURES

ALLIED HEALTH PROFESSIONAL POLICIES AND PROCEDURES PROVIDENCE HEALTH & SERVICES OREGON ALLIED HEALTH PROFESSIONAL POLICIES AND PROCEDURES Providence Hood River Memorial Hospital Providence Medford Medical Center Providence Milwaukie Hospital Providence

More information

THE MEDICAL STAFF ORGANIZATIONAL DOCUMENTS

THE MEDICAL STAFF ORGANIZATIONAL DOCUMENTS Medical Staff Administration / 251 E. Huron, Galter 3-104, Chicago, IL 60611 / Office: 312/926-2267 / Fax: 312/926-2019 THE MEDICAL STAFF ORGANIZATIONAL DOCUMENTS Bylaws Credentials Plan Hearing Plan Committee

More information

240 Maple Street PO Box 470 Woodruff, WI 54568 (715) 356-8000

240 Maple Street PO Box 470 Woodruff, WI 54568 (715) 356-8000 240 Maple Street PO Box 470 Woodruff, WI 54568 (715) 356-8000 Medical Staff Policy & Procedure NUMBER: MS.3 Effective/Approval Date: February 17, 1998 TITLE: ALLIED HEALTH PROFESSIONALS Revised 6/98; 5/99;

More information

Ontario Hospital Association/Ontario Medical Association Hospital Prototype Board-Appointed Professional Staff By-law

Ontario Hospital Association/Ontario Medical Association Hospital Prototype Board-Appointed Professional Staff By-law Ontario Hospital Association/Ontario Medical Association Hospital Prototype Board-Appointed Professional Staff By-law 2011 ONTARIO HOSPITAL ASSOCIATION/ ONTARIO MEDICAL ASSOCIATION HOSPITAL PROTOTYPE BOARD-APPOINTED

More information

MEDICAL STAFF BYLAWS FOR CHILDREN'S & WOMEN'S HEALTH CENTRE OF BRITISH COLUMBIA AN AGENCY OF THE PROVINICAL HEALTH SERVICES AUTHORITY

MEDICAL STAFF BYLAWS FOR CHILDREN'S & WOMEN'S HEALTH CENTRE OF BRITISH COLUMBIA AN AGENCY OF THE PROVINICAL HEALTH SERVICES AUTHORITY MEDICAL STAFF BYLAWS FOR CHILDREN'S & WOMEN'S HEALTH CENTRE OF BRITISH COLUMBIA AN AGENCY OF THE PROVINICAL HEALTH SERVICES AUTHORITY SEPTEMBER 1, 2004 Board Approved June 24, 2004 Ministry of Health Approved

More information

6325 Hospital Parkway Johns Creek, Georgia 30097 Phone 678-474-7000 emoryjohnscreek.com Dear Provider,

6325 Hospital Parkway Johns Creek, Georgia 30097 Phone 678-474-7000 emoryjohnscreek.com Dear Provider, Dear Provider, Thank you for your recent inquiry in credentialing at Emory Johns Creek Hospital. Through our affiliation with Emory Healthcare, we are pleased to announce that our application process is

More information

Please Note: Please send all documentation related to the credentialing portion of this documentation to:

Please Note: Please send all documentation related to the credentialing portion of this documentation to: Please ote: The application process is split into different actions. Please send all documentation related to the contracting portion of this documentation to: Fax to: (916)350-8860 Or email to: BSCproviderinfo@blueshieldca.com

More information

MARTIN HEALTH SYSTEM

MARTIN HEALTH SYSTEM MARTIN HEALTH SYSTEM CREDENTIALING PROCEDURES MANUAL FOR ALLIED HEALTH PROFESSIONALS/DEPENDENT PRACTITIONERS Last Amended September 24, 2014 Approved 04/2012 Last reviewed in its entirety by Medical Staff

More information

EL CAMINO AMBULATORY SURGERY CENTER MEDICAL STAFF BYLAWS DEFINITIONS

EL CAMINO AMBULATORY SURGERY CENTER MEDICAL STAFF BYLAWS DEFINITIONS El Camino Ambulatory Surgery Center, LLC 2480 Grant Road Mountain View, CA 94040 EL CAMINO AMBULATORY SURGERY CENTER MEDICAL STAFF BYLAWS Whereas, El Camino Ambulatory Surgery Center, LLC, organized under

More information

INTERNATIONAL SOCIETY OF ARBORICULTURE (ISA) CERTIFICATION PROGRAM ETHICS CASE PROCEDURES

INTERNATIONAL SOCIETY OF ARBORICULTURE (ISA) CERTIFICATION PROGRAM ETHICS CASE PROCEDURES INTERNATIONAL SOCIETY OF ARBORICULTURE (ISA) CERTIFICATION PROGRAM ETHICS CASE PROCEDURES INTRODUCTION. The ISA Certification Board develops and promotes high ethical standards for the Certified Arborist

More information

COMMUNITY HEALTH NETWORK ALLIED HEALTH PROFESSIONAL POLICY MANUAL

COMMUNITY HEALTH NETWORK ALLIED HEALTH PROFESSIONAL POLICY MANUAL COMMUNITY HEALTH NETWORK ALLIED HEALTH PROFESSIONAL POLICY MANUAL OBJECTIVE: To establish the method by which Allied Health Professionals may be granted clinical privileges and appointment to the Allied

More information

This policy applies to: Stanford Hospital and Clinics Lucile Packard Children s Hospital. Date Written or Last Revision: Oct 2012

This policy applies to: Stanford Hospital and Clinics Lucile Packard Children s Hospital. Date Written or Last Revision: Oct 2012 Providers Page 1 of 13 I. PURPOSE To establish mechanisms for gathering relevant data that will serve as the basis for decisions regarding credentialing and privileging of licensed independent practitioners

More information

Credentialing CREDENTIALING

Credentialing CREDENTIALING CREDENTIALING Based on standards set forth by the National Committee for Quality Assurance (NCQA) all Providers listed in literature for Molina Healthcare will be credentialed. All designated practitioners,

More information

BYLAWS OF THE MEDICAL STAFF

BYLAWS OF THE MEDICAL STAFF (EFFECTIVE 6.25.12) BYLAWS OF THE MEDICAL STAFF CENTRAL MAINE MEDICAL CENTER LEWISTON, MAINE With updates adopted by the Medical Staff on June 25, 2012 Edmund Claxton, M.D. President Approved by the Governing

More information

LIBERTY DENTAL PLAN Provider Credentialing Application

LIBERTY DENTAL PLAN Provider Credentialing Application (Complete one application per Provider) (* Required Fields) Credentialing Information: Owner: Associate: *PROVIDER NAME: DDS DMD Other (specify) *DATE OF BIRTH: / / Gender: Male Female Owning Dentist Name:

More information

Supplement to Clinical Training and ERAS Application

Supplement to Clinical Training and ERAS Application Supplement to Clinical Training and ERAS Application The Johns Hopkins Hospital 600 North Wolfe Street Baltimore MD 21287 Johns Hopkins Bayview Medical Center 4940 Eastern Avenue Baltimore MD 21224 The

More information

BoardroomBasics. Medical Staff Credentialing INSIDE. KNOWLEDGEPoints. Knowledge Resources for Health Care Governance Effectiveness

BoardroomBasics. Medical Staff Credentialing INSIDE. KNOWLEDGEPoints. Knowledge Resources for Health Care Governance Effectiveness BoardroomBasics Knowledge Resources for Health Care Governance Effectiveness Medical Staff Credentialing INSIDE Overview 1 What is Credentialing and Privileging? Roles and Responsibilities of Key Individuals

More information

CREDENTIALING PLAN SECTION ONE INDIVIDUAL PROVIDERS

CREDENTIALING PLAN SECTION ONE INDIVIDUAL PROVIDERS CREDENTIALING PLAN SECTION ONE INDIVIDUAL PROVIDERS I. STATEMENT OF POLICY A. The purpose of Avera Credentialing Verification Service (CVS) is to provide credentialing and recredentialing primary source

More information

North Carolina Delta Dental s Recredentialing Application

North Carolina Delta Dental s Recredentialing Application Delta Dental of North Carolina North Carolina Delta Dental s Recredentialing Application INCOMPLETE APPLICATIONS WILL BE RETURNED, WHICH WILL DELAY THE RECREDENTIALING PROCESS 1. The attached Recredentialing

More information

APPENDIX A MEDICAL STAFF CREDENTIALING POLICY

APPENDIX A MEDICAL STAFF CREDENTIALING POLICY APPENDIX A MEDICAL STAFF CREDENTIALING POLICY 1 TABLE OF CONTENTS 12/4/07 Version ARTICLE I: MEDICAL STAFF MEMBERSHIP...3 A. QUALIFICATIONS FOR MEMBERSHIP AND CLINICAL PRIVILEGES...3 1. General...3 2.

More information

MEDICAL STAFF BYLAWS OF THE UNIVERSITY OF ILLINOIS AT CHICAGO MEDICAL CENTER

MEDICAL STAFF BYLAWS OF THE UNIVERSITY OF ILLINOIS AT CHICAGO MEDICAL CENTER MEDICAL STAFF BYLAWS OF THE UNIVERSITY OF ILLINOIS AT CHICAGO MEDICAL CENTER Reviewed/Amended: May 19, 1983 August 17, 1988 December 19, 1989 August 23, 1990 August 22, 1991 January 22, 1992 May 6, 1992

More information

WELLSPAN EPHRATA COMMUNITY HOSPITAL MEDICAL STAFF BYLAWS PREAMBLE

WELLSPAN EPHRATA COMMUNITY HOSPITAL MEDICAL STAFF BYLAWS PREAMBLE WELLSPAN EPHRATA COMMUNITY HOSPITAL MEDICAL STAFF BYLAWS PREAMBLE These Bylaws originated with the Medical Staff and were approved by the Board. These Bylaws are adopted in order to organize the Medical

More information

Revised Elements of Performance for Rehabilitation and Psychiatric Distinct Part Units in Critical Access Hospitals

Revised Elements of Performance for Rehabilitation and Psychiatric Distinct Part Units in Critical Access Hospitals Revised Elements of Performance for Rehabilitation and Psychiatric Distinct Part Units in Critical Access Hospitals Effective January 1, 2010 Critical Access Hospital Accreditation Program Standard EC.0001

More information

DOCUMENT TITLE: Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy Outlined in Policy Information Notice 2001-16

DOCUMENT TITLE: Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy Outlined in Policy Information Notice 2001-16 2002-22 DATE: July 10, 2002 DOCUMENT TITLE: Clarification of Bureau of Primary Health Care Credentialing and Privileging Policy Outlined in Policy Information Notice 2001-16 Revision (October 30, 2014):

More information

PERSONAL DATA. 1. Name. 2. Other Name(s) Previously Used Effective Date. 3. Social Security Number 4. UPIN# 5. Medicaid #

PERSONAL DATA. 1. Name. 2. Other Name(s) Previously Used Effective Date. 3. Social Security Number 4. UPIN# 5. Medicaid # For Credentialing Staff Use Only Specialty Date Application Received Attach a recent 2 x 2 passport size photograph for the master file and each facility marked on this application Date Application Signature

More information

1) ELIGIBLE DISCIPLINES

1) ELIGIBLE DISCIPLINES PRACTITIONER S APPLICABLE TO ALL INDIVIDUAL NETWORK PARTICIPANTS AND APPLICANTS FOR THE PREFERRED PAYMENT PLAN NETWORK, MEDI-PAK ADVANTAGE PFFS NETWORK AND MEDI-PAK ADVANTAGE LPPO NETWORK. 1) ELIGIBLE

More information

JOHN DEMPSEY HOSPITAL MEDICAL STAFF BYLAWS. Revised 12-14-15

JOHN DEMPSEY HOSPITAL MEDICAL STAFF BYLAWS. Revised 12-14-15 JOHN DEMPSEY HOSPITAL MEDICAL STAFF BYLAWS Revised 12-14-15 2 MEDICAL STAFF BYLAWS AND RULES AND REGULATIONS OF THE MEDICAL STAFF OF JOHN DEMPSEY HOSPITAL OF UCONN HEALTH Revised copy Adopted by the Medical

More information

Allied Healthcare Professional (AHP) Professional Liability Application

Allied Healthcare Professional (AHP) Professional Liability Application Allied Healthcare Professional (AHP) Professional Liability Application Coverys RRG, Inc. Agency Name NOTICE: This policy is issued by your risk retention group. Your risk retention group may not be subject

More information

Community Health Group Allied Health Professional Application

Community Health Group Allied Health Professional Application Community Health Group Allied Health Professional Application Nurse Practitioner Certified Nurse Midwife LCSW Clinical Psychologist MFCC Other I. INSTRUCTIONS This form should be typed or legibly printed

More information

ALLIED HEALTH PROFESSIONALS MANUAL

ALLIED HEALTH PROFESSIONALS MANUAL ALLIED HEALTH PROFESSIONALS MANUAL Allen Memorial Hospital Waterloo, Iowa Reviewed & Revised: November 2011 New: January 2005 Replaces: Sections of Medical Staff Manual and Credentials Manual ALLEN MEMORIAL

More information

PARKVIEW WHITLEY HOSPITAL MEDICAL STAFF BYLAWS

PARKVIEW WHITLEY HOSPITAL MEDICAL STAFF BYLAWS PARKVIEW WHITLEY HOSPITAL Columbia City, Indiana MEDICAL STAFF BYLAWS Full Review & Rewritten, as needed March 1982, February 1987, April 1990, May 1997, July 2000, May 2003, June 2006, August 2009, February

More information

COLORADO DEPARTMENT OF REGULATORY AGENCIES. Division of Professions and Occupations Office of Speech-Language Pathology Certification

COLORADO DEPARTMENT OF REGULATORY AGENCIES. Division of Professions and Occupations Office of Speech-Language Pathology Certification COLORADO DEPARTMENT OF REGULATORY AGENCIES Division of Professions and Occupations Office of Speech-Language Pathology Certification 4 CODE OF COLORADO REGULATIONS (CCR) 748-1 RULES REGULATING SPEECH-LANGUAGE

More information

PERSONAL DATA NOTE: SHADED PORTIONS N/A TO ALLIED HEALTH PROFESSIONALS. 1. Name. 2. Other Name(s) Previously Used Effective

PERSONAL DATA NOTE: SHADED PORTIONS N/A TO ALLIED HEALTH PROFESSIONALS. 1. Name. 2. Other Name(s) Previously Used Effective For Credentialing Staff Use Only Specialty Date Application Received Attach a recent 2 x 2 passport size photograph for the master file and each facility marked on this application Date Application Signature

More information

PHYSICIANS REIMBURSEMENT FUND, INC. A Risk Retention Group. APPLICATION MD & DO Locum Tenens. 1. First Name: Middle Initial: Last Name:

PHYSICIANS REIMBURSEMENT FUND, INC. A Risk Retention Group. APPLICATION MD & DO Locum Tenens. 1. First Name: Middle Initial: Last Name: PHYSICIANS REIMBURSEMENT FUND, INC. A Risk Retention Group APPLICATION MD & DO Locum Tenens Applicant Information: 1. First Name: Middle Initial: Last Name: CA Medical License #: Expiration Date: Date

More information

The University of Utah Health Plans offers the following plans and networks. Please specify the networks you are interested in participating with:

The University of Utah Health Plans offers the following plans and networks. Please specify the networks you are interested in participating with: Provider Networks Provider Applicant Process University of Utah Health Plans (UUHP) contracts with physicians and other health care professionals and facilities to offer provider networks essential to

More information

ST. JOHN S HOSPITAL-ALLIED HEALTH PROFESSIONALS ADVANCED PRACTICE NURSE IN THE EMERGENCY DEPARTMENT

ST. JOHN S HOSPITAL-ALLIED HEALTH PROFESSIONALS ADVANCED PRACTICE NURSE IN THE EMERGENCY DEPARTMENT ST. JOHN S HOSPITAL-ALLIED HEALTH PROFESSIONALS ADVANCED PRACTICE NURSE IN THE EMERGENCY DEPARTMENT (APN) In accordance with the Nursing and Advanced Practice Nursing Act (225 ILCS 65) (the Act ), the

More information

Medical Staff Allied Health Professional Policy

Medical Staff Allied Health Professional Policy Medical Staff Allied Health Professional Policy MOUNT CARMEL HEALTH SYSTEM A Medical Staff Document \\Mcehemcshare\mchs med staff svcs$\misc\governing Documents\MCHS\AHP Policy\MCHS Medial Staff Allied

More information

POLICY No. 20-049. Prepared by: Judith Kell Effective: December 20, 2002 Compliance Review Supervisor Revised: January 23, 2009

POLICY No. 20-049. Prepared by: Judith Kell Effective: December 20, 2002 Compliance Review Supervisor Revised: January 23, 2009 LAKESHORE BEHAVIORAL HEALTH ALLIANCE Community Mental Health Services of Muskegon County Community Mental Health of Ottawa County Lakeshore Coordinating Council for Substance Abuse Services POLICY Prepared

More information

MUNICIPAL REGULATIONS for CLINICAL NURSE SPECIALISTS

MUNICIPAL REGULATIONS for CLINICAL NURSE SPECIALISTS MUNICIPAL REGULATIONS for CLINICAL NURSE SPECIALISTS CHAPTER 60 CLINICAL NURSE SPECIALIST Secs. 6000 Applicability 6001 General Requirements 6002 Term of Certificate 6003 Renewal of Certificate 6004 Educational

More information

EMPLOYMENT/CREDENTIALING APPLICATION

EMPLOYMENT/CREDENTIALING APPLICATION Beacon Specialized Living Services, Inc. EMPLOYMENT/CREDENTIALING APPLICATION We do not discriminate on the basis of race, color, religion, national origin, sex, age or disability. It is our intention

More information

Credentialing and Privileging. Mary Coffey, MBA, RN Executive Director, Kenosha Community Health Center

Credentialing and Privileging. Mary Coffey, MBA, RN Executive Director, Kenosha Community Health Center Credentialing and Privileging Mary Coffey, MBA, RN Executive Director, Kenosha Community Health Center 1 The goal of this Continuing Education Program is to provide health care professionals with information

More information

Terrebonne General Medical Center 8166 Main Street Houma, Louisiana 70360 Human Resources (985) 873-4628 Phone 985-873-4481 Fax

Terrebonne General Medical Center 8166 Main Street Houma, Louisiana 70360 Human Resources (985) 873-4628 Phone 985-873-4481 Fax Terrebonne General Medical Center 8166 Main Street Houma, Louisiana 70360 Human Resources (985) 873-4628 Phone 985-873-4481 Fax APPLICATION FOR APPOINTMENT TO THE NON-CLINICAL ALLIED HEALTH STAFF Instructions

More information

PHYSICIAN APPLICATION FOR EMPLOYMENT

PHYSICIAN APPLICATION FOR EMPLOYMENT PLEASE COMPLETE The Following. DATE Name Last First Middle Maiden Address City State Zip Date of Birth Place of Birth Social Security Number US Citizen Home Phone Email Address Specialty/Sub-specialty

More information

It s Time for You to be Recredentialed!

It s Time for You to be Recredentialed! It s Time for You to be Recredentialed! Thank you for participating in the Delta Dental of Massachusetts network. In accordance with the National Committee for Quality Assurance guidelines, dentists are

More information

CHARTERED PROFESSIONAL ACCOUNTANTS OF ONTARIO

CHARTERED PROFESSIONAL ACCOUNTANTS OF ONTARIO CHARTERED PROFESSIONAL ACCOUNTANTS OF ONTARIO REGULATION 9-1 PUBLIC ACCOUNTING LICENSING Adopted by the Council pursuant to the Chartered Accountants Act, 2010, and the Bylaws on June 16, 2011, as amended

More information

GENESEE COUNTY Date Issued: 01-1999 COMMUNITY MENTAL HEALTH Date Revised: 08-2011 PIHP POLICY MANUAL SUBJECT:

GENESEE COUNTY Date Issued: 01-1999 COMMUNITY MENTAL HEALTH Date Revised: 08-2011 PIHP POLICY MANUAL SUBJECT: GENESEE COUNTY Date Issued: 01-1999 COMMUNITY MENTAL HEALTH Date Revised: 08-2011 PIHP POLICY MANUAL SUBJECT: Page 1 of 7 WRITTEN BY: T. Deeghan, COO TECHNICAL REVIEW BY: T. Deeghan, S. Mason AUTHORIZED

More information

Guidelines for Updating Medical Staff Bylaws: Credentialing and Privileging Physician Assistants (Adopted 2012)

Guidelines for Updating Medical Staff Bylaws: Credentialing and Privileging Physician Assistants (Adopted 2012) Guidelines for Updating Medical Staff Bylaws: Credentialing and Privileging Physician Assistants (Adopted 2012) Executive Summary of Policy Contained in this Paper Summaries will lack rationale and background

More information

MEDICAL STAFF & ALLIED HEALTH PROFESSIONAL STAFF BYLAWS

MEDICAL STAFF & ALLIED HEALTH PROFESSIONAL STAFF BYLAWS MEDICAL STAFF & ALLIED HEALTH PROFESSIONAL STAFF BYLAWS * * * MARYMOUNT HOSPITAL GARFIELD HEIGHTS, OHIO 44125 Board of Trustees Approved 08.18.15 1 TABLE OF CONTENTS PREAMBLE... 6 DEFINITIONS... 7 ARTICLE

More information

Please read the information below to assist you in submitting the on-line application and the supplemental forms.

Please read the information below to assist you in submitting the on-line application and the supplemental forms. DMC Corporate Medical Affairs/CVO 4707 St. Antoine, Ste. E510/Hutzel Building Mail Code 522 Detroit, Michigan 48201-1498 313-993-0203 Phone 313-993-0010 Fax Dear Applicant: Thank you for your interest

More information

CRAIG HOSPITAL ENGLEWOOD, COLORADO BYLAWS OF THE MEDICAL STAFF ADOPTED AS AMENDED: MARCH 26, 2015

CRAIG HOSPITAL ENGLEWOOD, COLORADO BYLAWS OF THE MEDICAL STAFF ADOPTED AS AMENDED: MARCH 26, 2015 CRAIG HOSPITAL ENGLEWOOD, COLORADO BYLAWS OF THE MEDICAL STAFF ADOPTED AS AMENDED: MARCH 26, 2015 BYLAWS OF THE MEDICAL STAFF 48355590.5 TABLE OF CONTENTS PAGE PREAMBLE... 1 DEFINITIONS...1 ARTICLE I.

More information

WCHO PIHP POLICY for the COMMUNITY MENTAL HEALTH PARTNERSHIP OF SOUTHEASTERN MICHIGAN Department: Business Finance Administration Author: S.

WCHO PIHP POLICY for the COMMUNITY MENTAL HEALTH PARTNERSHIP OF SOUTHEASTERN MICHIGAN Department: Business Finance Administration Author: S. WCHO PIHP POLICY for the COMMUNITY MENTAL HEALTH PARTNERSHIP OF SOUTHEASTERN MICHIGAN Department: Business Finance Administration Author: S. Reitmeier Date: Reason: Revision Date 03/07, 10/09 Policy and

More information

MUNICIPAL REGULATIONS for NURSE PRACTITIONERS

MUNICIPAL REGULATIONS for NURSE PRACTITIONERS MUNICIPAL REGULATIONS for NURSE PRACTITIONERS CHAPTER 59 NURSE-PRACTITIONERS Secs. 5900 Applicability 5901 General Requirements 5902 Term of Certificate 5903 Renewal of Certificate 5904 Educational Requirements

More information

Comprehensive Geriatric Medicine d/b/a Doctors on Call Provider Employment Application

Comprehensive Geriatric Medicine d/b/a Doctors on Call Provider Employment Application Comprehensive Geriatric Medicine d/b/a Doctors on Call Provider Employment Application Thank you for your interest in employment at Comprehensive Geriatric Medicine d/b/a Doctors on Call. As a leader in

More information