APPLICATION AFFILIATE STAFF APPOINTMENT CROUSE HOSPITAL

Transcription

1 APPLICATION AFFILIATE STAFF APPOINTMENT CROUSE HOSPITAL 1. Identifying Information Last Name Maiden Name First Name Initial Residence Address City State Zip Code Home Phone Number Social Security Number Date of Birth Place of Birth Citizenship NPI Number (if applicable): 2. General Professional Information Group Name Department Partners / Associates Office Address City State Zip Code Phone Number 2 nd Office Address City State Zip Code Phone Number 3. Privileges Desired I am applying for appointment to the Affiliate Staff in the specialty of: Check one please Podiatry Certified Nurse Midwife Clinical Psychology Other (please specify):

2 4. Professional Education Professional School Degree Address Date of Graduation 5. Post-Graduate Education Program Location Dates Degree Program Location Dates Degree Program Location Dates Degree 6. Certification and Recertification Certified by: Date: Certificate No.: Date expires: Last Recertification: Date: Certificate No.: Date expires: Certified by: Date: Certificate No.: Date expires: Last Recertification: Date: Certificate No.: Date expires: 7. NYS Licenses Number Number Number

3 Professional licenses from other states, past and present State Date License Number Discipline State Date License Number Discipline Drug Enforcement Admin. (DEA) Registration Number 8. Military Service Information Dates of Service Branch Location 9. Professional Society Memberships Society Society Society 10. Current Academic Appointments Title Institution Dates Title Institution Dates

4 11. Past Practices or Professional Employment List in chronological order This differs from hospital affiliations, unless you were employed by the hospital. 12. Hospital Affiliations (all past and present) 13. Professional Liability Insurance Information Current Insurance Carrier Policy Period Policy Number Policy Limits Address Phone/Fax 14. List all previous professional liability insurance carriers.

5 14. Continuing Education On a separate sheet of paper list: All continuing education activities which you have attended or for which you have received credit in the past two years which related to your professional discipline or clinical privileges requested. 15. Professional References (List three professionals the healthcare industry who can speak to your personal integrity and professional competency.) 1. Name Address Phone / Fax Relationship 2. Name Address Phone / Fax Relationship 3. Name Address Phone / Fax Relationship Miscellaneous Information Are you now or were you ever subject to: (Provide full details for positive answers on separate sheet) Yes No a. previously successful or currently pending limitation, suspension, revocation or voluntary surrender or license or registration to practice in any jurisdiction? b. previously successful or currently pending limitation, suspension, revocation or voluntary surrender of Drug Enforcement Administration (DEA) registration? c. limitation, suspension, revocation, denial, non-renewal or luntary surrender of employment, appointment or privileges at any hospital or health care related institution?

6 d. investigation, corrective action, or discipline by any hospital or health care related institution for any reason, including patient complaints? e. pending professional malpractice claims or actions, professional misconduct proceedings or licensing board actions in any jurisdiction? (See enclosed) f. any judgment, settlement, or findings of any malpractice or any finding of professional misconduct in any jurisdiction? g. suspension, sanction or other restriction in participation in any private, federal or state insurance program i.e. Medicare)? h. 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? i. criminal convictions or pending criminal proceedings for felonies or misdemeanors? j. malpractice premium rating, surcharge, malpractice insurance cancellation, denial or non renewal? k. any physical or mental impairment (including drugs and / or alcohol) which would prevent you from carrying out the responsibilities of affiliate medical staff membership 17. Affirmation of Information The undersigned hereby affirms under penalties of perjury as follows: that he/she is the applicant named Herein; that he/she has read the foregoing application and knows the content thereof; that the same is complete, true and accurate to his/her own knowledge and belief. Signature Date Please Print Your Name

7 18. Authorization for Release of General Information I hereby make application for appointment to the Affiliate Medical Staff of Crouse Hospital, hereinafter referred to as Hospital, and for clinical privileges as requested in the attached documents. I fully understand that any significant misstatements in or omissions form this application constitute cause for denial of appointment to or cause for summary dismissal from the Medical Staff. I acknowledge that I have received (and had an opportunity to read) the Constitution and Rules and Regulations of the Medical Staff and that I have been advised that the Bylaws of the Hospital, the JCAHO Accreditation Manual for Hospitals and the New York State Hospital Code are available in the Medical Affairs Office for my review. I agree to be bound by the terms of the Constitution and Rules and Regulations of the Medical Staff and Hospital Bylaw if I am granted membership or clinical privileges. I further agree to be bound by the terms there of, even if I am not granted membership or clinical privileges, in all matters relating to the consideration of my application for appointment to the Medical Staff. I further agree to abide by such Hospital Bylaws and Medical Staff Constitution and Rules and Regulation as may be from time to time enacted. By applying for appointment to the Medical Staff I hereby signify my willingness to appear for interviews in regard to my application and authorize the Hospital, its medical staff and their representatives to consult with administrators and members of the 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, its medical staff and its 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 and its medical staff for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and I hereby release from any liability any and all individuals and organizations who provide information to the Hospital, or its medical staff, in good faith and without malice concerning my professional competence, ethics, character and other qualifications for staff appointment and clinical privileges, and I hereby consent to the release of such information. I hereby further authorize and consent to the release of information by the Hospital, or its medical staff to other hospitals, government agencies and medical associations on request regarding any information the Hospital and the medical staff may have concerning me as long as such release of information is done in good faith and without malice, and I hereby release from liability the Hospital, its employees and its medical staff for so doing. All such correspondence shall be available to me. I understand and agree that I, as applicant for Medical staff membership have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics and other qualifications and for resolving any doubts about such qualifications. I have not requested privileges for any procedures for which I am not qualified. 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 exercising any privileges on the Medical Staff at Crouse Hospital. Furthermore, I agree to serve, when requested, on the various committees of the Medical Staff, to perform other assignments made by the officers of the Medical Staff or the Chief of the department to which I shall be appointed, and to keep my medical record current. I hereby affirm under the penalties of perjury as follows: that I am the applicant named hearin; that I have read the foregoing Authorization and know the contents thereof. I accept the stipulations and obligations and authorize the releases therein contained. Please Print Your Name Signature of Applicant Date