Anesthesia Staffing Solutions. CRNA Application

Transcription

1 Anesthesia Staffing Solutions CRNA Application Name of Applicant: Address: City/State/Zip: Telephone: Home: Work: Cell: E- mail: Date of Birth: Country/State of Birth Social Security Number: Driver s License Number: Are you a US Citizen: Position Desired: Locum Tenens? Permanent? Both? Date Available: Foreign Languages Spoken: Geographical Preference: Current Licensure: Pending Licensure: Nursing School Attended: Address of Nursing School: Phone # of Nursing School: Dates Attended: Anesthesia School Attended: Address of Anesthesia School: Phone # of Anesthesia School: Anesthesia Program Director: Phone # of Anesthesia Director:

2 Yr CRNA Certification Received: Health Status: Do you have any physical or mental conditions, including chemical/substance dependency that would compromise your ability to practice as a CRNA or perform appropriate clinical duties? Have you used drugs recreationally, or have you ever been treated for alcoholism, narcotic addiction or mental illness? Do you need special accommodations to carry out daily responsibilities as a CRNA? * If you answered yes to any of the above questions, please provide details on a separate sheet. In case of emergency please notify: (name) (phone) (relation) Malpractice Insurance Information: Name of your current carrier: Do you presently have occurrence coverage? Did you purchase tail coverage from your present carrier? Have you ever been a party in or been involved in any malpractice claim or suit? *If yes, when? Do you have any knowledge of any occurrence or circumstance that is likely to result in a malpractice claim or suit against you? * If you answered yes to any of the above Malpractice Insurance questions, please provider details on a separate sheet. Disciplinary Actions: Have you ever been the subject of any investigation by any private, state, or federal health insurance programs or any other governmental agency? Have you ever been suspended from Medicare/Medicaid Program? Has your license to practice as a RN or CRNA ever been denied, revoked, suspended or in any way limited? Have you ever been censored by any committee of a state or county medical association with regard to ethics or fees?

3 Have your staff privileges ever been denied, suspended or in any way restricted at any facility? Have you ever been subject of a licensing board inquiry? Have you ever been denied a state medical license? Has any insurance carrier ever declined, canceled, or refused to renew your professional liability insurance? Have you ever been denied HMO, PPO, or other health plan participation? Have you ever voluntarily surrendered your CRNA license, staff privileges or consented to a limitation of the same pending a review or investigation? Are there any other issues that should be disclosed that may have an adverse impact on you ability to deliver effective medical services? * If you answered yes to any of the above Malpractice Insurance questions, please provide details, on a separate sheet. Professional References: (please list at least 4). Please include name, address and phone # Additional Education/Prior Employment: Please attach a current CV with this application. If you do no have an updated CV please list pertinent dates including education and employment, on a separate sheet. The delineated list of clinical privileges should be completed to reflect your pattern of practice. You should request the privileges on the basis of your training, experience a demonstrated competence. This list is intended as a guide, not as an all- inclusive list.

4 I,, CRNA request the following clinical privileges based on training, experience and competences. ( ) Preanesthetic assessment ( ) Requesting laboratory/diagnostic studies ( ) Preanesthetic medication ( ) General anesthesia/adjunctive drugs ( ) Regional anesthesia techniques ( ) Subarachnoid ( ) Epidural ( ) Caudel ( ) Upper extremity ( ) Lower extremity ( ) Diagnostic and therapeutic nerve blocks ( ) Local infiltration ( ) Topical ( ) Periocular block ( ) Transtracheal ( ) Intracapsular ( ) Intercostal ( ) Other (please specify) ( ) Other (please specify) ( ) Cardiopulmonary resuscitation management ( ) Perianesthetic invasive and noninvasive monitoring ( ) Tracheal intubation/extubation ( ) Mechanical ventilation/oxygen therapy ( ) Fluid, electrolyte, acid- base management ( ) Administration of blood, blood products, plasma expanders ( ) Peripheral intravenous/arterial catheter placement ( ) Central venous catheter placement ( ) Pulmonary artery catheter placement ( ) Acute and chronic placement ( ) Post Anesthesia Care Unit (PACU) discharge ( ) Conscious and deep sedation techniques ( ) Perianesthesia mgmt.. of patient using accessory drugs or fluids ( ) Adult ( ) Pediatric ( ) Other (please specify) ( ) Other (please specify) Release and Authorization:

5 I,, CRNA hereby authorize Anesthesia Staffing Solution, LLC to obtain any information that may be relevant to an evaluation of my professional qualifications, including information about disciplinary actions or other confidential privileges information. I authorize the release of all information necessary from all school, colleges, universities, transcript offices, medical institutions, hospital, employers, personal references, physicians, attorneys, medical malpractice carriers, the National Practitioners Data Bank, the Federation of State Boards and any other pertinent source. I hereby indemnify and hold harmless Anesthesia Staffing Solutions, LLC, it s agents, officers and employees, as well as any third parties, including, but not limited to the Federal of State Medical Boards and others, from any damages or liability civil or otherwise, from any acts performed in good faith without malice and in connection and verification of such information. I hereby authorize all current and prior malpractice carriers to release policy information, including all coverage and claim information. A copy of this document shall operate as full proof of authority and release. Name: Signature: Date: