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1 Medical Staff Services Washington Blvd. Whittier, CA T: Ext F: E: WELCOME! Thank you for your interest in PIH Health Hospital - Whittier. The enclosed questionnaire must be completed. If you meet the qualifications and criteria required for clinical privileges, an Application for Membership and Clinical Privileges will be sent. The Radiology and Emergency Medicine Departments are exclusive services available only through the contracted groups. No independent applications will be accepted. If you would like information on how to contact these groups, please give us a call and we will direct you. The following items are required to be eligible to apply for medical staff membership and clinical privileges: California medical license Current federal DEA registration certificate with all schedules noted. X-ray supervisor operator license (if applicable). For physicians: evidence of board certification or eligibility, which is recognized by an American Board of Medical Specialties (ABMS) or the Osteopathic Board of Medical Specialties or the American Board of Podiatric Surgery. Dentists and clinical psychologists are exempt from this requirement as there is no ABMS board from which to obtain certification For allied health professionals (NP, PA, RNFA, CNM): evidence of certification where certification exists. Evidence that you satisfactorily completed an approved postgraduate training program within your specialty. Certificate of professional liability coverage that meets the requirement of the Board of Directors. (See the attached policy for specific requirements). Evidence of current experience and competency in exercising the privileges requested. Credentialing of new applicants is a two-step process at PIH Health. The first step is the review of the pre-application forms. If all requirements have been met, an application will be mailed to you. The applicant is responsible for producing information for an adequate evaluation. Intentional failure to disclose derogatory information at the initial time of credentialing will result in an automatic denial of the application. Should you have any questions regarding the credentialing process, please call the Medical Staff Services Department at Ext Sincerely, C. Wayne Ray, MD President, Medical Staff Page 1 of 6

2 PIH HEALTH HOSPITAL WHITTIER MEDICAL STAFF PRE-APPLICATION FORM Pre-application Instructions: Complete the pre-application in full. The pre-application must be typed or neatly printed. Attach additional sheets if there is insufficient space on this pre-application to complete your response. Please submit the completed, signed pre-application to: PERSONAL INFORMATION: PIH Health Hospital - Whittier Medical Staff Services E Washington Blvd. Whittier, CA Fax: Name: Medical Degree: Social Security Number: Cell/Pager Number: Date of Birth: Primary Office Address: Primary Office Phone: Office Manager Name: Office Fax: Office Manager Primary Specialty: Subspecialty(ies): Were you previously affiliated with this hospital? YES (year) NO PROFESSIONAL INFORMATION: Are you or will you be affiliated with other physician(s) or group(s)? If so, who? Who will provide the coverage for your patients if you are unavailable? Physician must be a Medical Staff Member in similar clinical privileges. Have you taken time away from Medical Practice? When, and for what reason? BOARD CERTIFICATION required: For Medical Staff Members re-certification required within 3 years of expiration. Page 2 of 6

3 Applicants who are in the exam track for board certification must become board certified within five years of appointment to the Medical Staff. Name of Board Specialty Date Certified Expiration Date If you are not board certified, what is your current status in the certification process? Date scheduled for your exam PROFESSIONAL LIABILITY INSURANCE (See attached Medical Staff Malpractice Insurance Policy ) Present Carrier (Provide a copy of your current Policy(ies) that covers at least 7 years) Does your present policy cover you for all the clinical privileges you are requesting? Yes No* (Please explain*) Have there been or are there currently any pending malpractice claims, suits, settlements, or arbitration proceedings involving your professional practice within the last 7 years? If yes, please explain by completing the professional liability information form enclosed (duplicate the form as needed). No Yes DISCIPLINARY ACTIONS: (explain in detail any disciplinary actions taken against you for any of the following): Medical license in any state DEA controlled substance registration Membership or clinical privileges on any hospital medical staff Professional society/fellowship or board certification membership Any other type of professional sanction Professional liability insurance Felony charges brought against you Government sanctions Page 3 of 6

4 CLINICAL PRIVILEGES A physician must meet minimum criteria to be eligible to apply for privileges that are outlined on the application for clinical privilege form enclosed specific to each specialty. Complete the clinical privilege form by designating your request, sign and date where indicated. Submit a copy of current experience from another facility(ies). I certify that the statements made and submitted for review are accurate. I understand that the hospital is not obligated to grant me medical staff membership or clinical privileges by accepting this preapplication. I understand and agree to answer similar questions that are made a part of the California Participating Application. SIGNED DATE Page 4 of 6

5 MEDICAL STAFF MALPRACTICE INSURANCE POLICY All applicants for appointment or reappointment to the Medical Staff, and all members of the Medical Staff, (excluding Retired and Honorary categories) shall have in full force and effect at the time of such application, and during the entire term of such membership, professional Errors and Omissions liability (malpractice) insurance coverage in amounts at least equal to the minimum standards (amounts) set below: Professional Liability Insurance. Acceptable professional liability insurance meeting all of the following requirements: 1.1 Minimum policy limits of $1,000,000 for each claim and $3,000,000 annual aggregate for physicians; or $500,000 for each claim and $1,000,000 annual aggregate for psychologists, dentists, oral surgeons, podiatrists, and allied health professionals. 1.2 Carrier must be licensed by the State of California Insurance Commission to operate in this state; alternatively, Surplus Lines Insurance Companies must be currently listed on the State of California Department of Insurances List of Eligible Surplus Lines Insurers. 1.3 Admitted licensed carriers shall have an AM Best rating of B+VII or better; eligible Surplus Lines Insurers must have an AM Best rating of A-XII or better. 1.4 Proof of insurance, depositing a copy of a valid, current insurance certificate with the Medical Staff Office; 1.5 Carrier already approved by the Board of Directors as an exception to the Policy requirements. Alternative Liability Coverage. Alternative liability coverage sources such as RRG coverage formed under the U.S. Federal Government Risk Retention Guidelines or Special Purpose Insurance including Captives, PCCs, and PGs meeting all of the following requirements: 2.1 Minimum policy limits of $1,000,000 for each claim and $3,000,000 annual aggregate for physicians; or $500,000 for each claim and $1,000,000 annual aggregate for psychologists, dentists, oral surgeons, podiatrists, and allied health professionals; 2.2 Carrier shall have an AM Best rating of A-V or higher; 2.3 (Proof of Insurance) 2.4 RPGs, PCCs, Captives, or Special Purpose Insurers insured by an insurance company otherwise meeting in the requirements of this Policy shall be acceptable; 2.5 RPGs, PGs, Captives, or Special Purpose Insurers maintaining an AM Best rating meeting or exceeding the AM Best rating required by this Policy shall be deemed acceptable; 2.6 RRGs, PG, Captives, PCC, or other Special Purpose Insurance already approved by the Board of Directors as an exception to the Policy requirements; 2.7 All other RPGs, PGs, PCCs, Captives, or Special Purpose Insurers shall be approved or rejected, as the case may be, by the Board of Directors pursuant to the exceptions procedure noted below. Exceptions. All exceptions to the foregoing Policy, if any, shall be made by the Board of Directors in its sole and absolute discretion. In exercising this discretion, the Board shall conduct an evaluation of the proposed insurer, RPG, PG, Captive, or Special Purpose Insurer which may include, but is not limited to, evaluating its capitalization; commitment to members; business plan; underwriting structure; risk management protocol; and claims management procedures. The decision of the Board of Directors shall be conclusive and binding. Page 5 of 6

6 * * C O N F I D E N T I A L * * P R O F E S S I O N A L L I A B I L I T Y I N F O R M A T I O N F O R M Practitioner Name: Case Name and Number: MUST BE COMPLETED IN ITS ENTIRETY, and TO THE BEST OF YOUR ABILITY. Patients Name: Age: Sex: M F Other Named Defendants: Date of Occurrence: Allegations (e.g., negligence, fraud, illegality, etc.): a. Condition and diagnosis at time of incident: b. Treatment and procedures provided: c. Patients condition subsequent to treatment or procedures: Claim Disposition (check ONE): OPEN CLOSED DISMISSED SETTLEMENT JUDGEMENT If CLOSED, indicate date CLOSED and the manner in which resolved: Date: Total amount of settlement or judgment: $ Amount paid on your behalf: $ (If confidentiality or any other privilege is claimed as to the status of a proceeding or the terms of settlement, please explain.) The above information is true and correct and I understand it becomes part of my application as submitted. NAME (Print) SIGNATURE DATE Page 6 of 6

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