DUE DATE: Please note: There will be a $175 late fee assessed for any packets that are received incomplete or not returned prior to this date.

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1 Dear Medical/Adjunct Staff Member: It is time for your biannual reappointment to the Medical Staff/Adjunct Staff of The University Hospital. Attached, you will find your application and delineation of privileges. You can also download the application from the Medical Staff Home Page: Please include the following: 1. A Copy of your Board Certification, if new or renewed since last reappointment. 2. You must submit the required documentation for Continuing Medical Education. Physicians, you need to submit the same requirements for licensure, 40 Category One and 60 Category 2. All other providers must submit what is required in order to maintain certification in their specialty. 3. Volunteers Please provide a copy of your current malpractice certificate. The certificate must list University Hospital as a certificate holder, and the limits must reflect $1million/$3million. If you have any questions regarding this requirement, you can contact our Risk and Claims Department at Please Provide Current ACLS/PALS/ATLS or NALS Certificates, it is mandatory if you are requesting privileges in Conscious Sedation. 5. PLEASE PROVIDE PROOF OF CURRENT PPD (within past twelve months) or CHEST X-RAY RESULTS FROM PRIVATE PHYSICIAN (If not UMDNJ employee if UMDNJ employee, please call OMS at ). You may not plant and read your own PPD. DUE DATE: Please note: There will be a $175 late fee assessed for any packets that are received incomplete or not returned prior to this date.. Please call Ms. DarLene Francis at if you have any questions regarding your reappointment. Thank you for your continued cooperation. Sincerely, Donna A. Cuddeback Program Administrator Medical Staff Administration Please Note: There is a mandatory Joint Commission requirement of Ongoing Professional Practice Evaluation for practitioners that have privileges at University Hospital. In order for you to be reappointed, your department must have a file with current information attesting to your competency for the privileges you are requesting. Volunteers you may be required to obtain information from your primary affiliation. Initials: - 1 -

2 Application for Reappointment to the Medical Staff INSTRUCTIONS: 1. Complete the application in full and print legibly. Sign, date and initial on the bottom of each page. 2. If additional space is needed to complete your response(s), use a blank paper or attach the supplemental documentation. 3. Submit all documentation that is requested (see cover letter). 4. Attach completed and signed list of requested clinical privileges, including appropriate certification(s) where applicable. 5. You must include copies of your CME activity or primary source documentation of CME s. 6. The New Jersey Heath Code requires that you provide documentation of an annual PPD or chest x-ray results. ***NOTE: If you should make an error on the application, please do not use white out. Cross out any mistakes and initial. Completed reappointment paperwork must be received and submitted to the appropriate committees for recommendation and approval. This is a lengthy process and requires your immediate attention. Thank you. D. A. Cuddeback, Director Medical Staff Administration Print Name: Department: Division: Please check one of the following: I am a paid F/T or P/T faculty member of UMDNJ Adjunct Staff APN, CRNA, PA, Psychologist I am a volunteer practitioner (insurance certificate required listing UH as a certificate holder) Other: (please explain) Initials: - 2 -

3 Medical Staff Reappointment Questionnaire I. PLEASE COMPLETE ALL INFORMATION AND INITIAL ALL PAGES Name: Home Address: Office Address: City: State: Zip: Address: Beeper #: Cell Phone #: Home Phone #: Work Phone #: Fax #: II. Board Certified: No Yes (Please provide information below) Name of Board: Name of Board: Name of Board: Exp. Exp. Exp. If you are not board certified, are you exam admissible? No Yes When do you plan to take the exam? III. Peer Review Recommendation: The Joint Commission requires peer recommendation from an authoritative source for reappointment to the medical staff. Please provide the name and complete address of one peer (do not list partners). The definition of a peer is an appropriate practitioner in the same professional discipline that has personal knowledge of the applicant and can speak to current competence (within last two years), experience and training. PLEASE DO NOT LIST YOUR CHIEF OF SERVICE OR DIRECTOR AT UNIVERSITY HOSPITAL. Name: Address: City: State: Zip: ADDRESS: PHONE #: FAX #: ALTERNATE: Name: Address: City: State: Zip: ADDRESS: IV. Language(s) spoken in addition to English: Initials: - 3 -

4 * If yes to any questions, please provide a complete explanation on a separate sheet of paper or on the reverse side of this page. The explanation must provide information as to whether the action has occurred since the date of your last reappointment and include the background of the action on the substance of the findings in such action or proceeding. 1. Has your license or registration to practice your profession in this state or any elsewhere has ever been voluntarily or involuntarily limited, suspended, revoked, denied, reduced, surrendered, non-renewed relinquished, subject to probationary condition, or have challenges or proceedings toward any of those ends ever been instituted, concerning that license or registration? 2. Has your Drug Enforcement Agency (DEA) or NJ CDS authorization ever been voluntarily or involuntarily limited, suspended, revoked, denied, reduced, surrendered, non-renewed, relinquished, subject to probationary conditions, or have challenges or proceedings toward any of those ends ever been instituted? 3. Have proceedings ever been instituted to have your board certification or eligibility voluntarily limited, suspended, revoked, denied, reduced surrendered, not renewed, relinquished, subject to probationary conditions, or have challenges or proceedings toward any of those ends ever been instituted? 4. Has your medical staff membership, medical staff status, clinical privileges, association, employment, practice or training at any hospital or healthcare facility ever been voluntarily or involuntarily, in whole or part, limited, suspended, revoked, denied, reduced, surrendered, not renewed, relinquished, subject to probationary conditions, or have proceedings toward any of those ends ever been instituted or recommended by a medical staff official, committee or governing body or are such proceeding pending in New Jersey State or elsewhere, concerning the above? 5. Has your request for any specific clinical privilege(s) ever been denied or granted with stated limitations (aside from ordinary and initial requirements of Proctorship) or have proceedings toward any of those ends ever been instituted or recommended by a medical staff official, committee or governing body or are such proceedings pending in New Jersey or elsewhere? 6. Has there ever been a finding or allegation of professional misconduct against you, or are there any professional misconduct proceedings pending against you in New Jersey or elsewhere? 7. Have you ever voluntarily or involuntarily relinquished, limited or reduced your medical staff membership, association, employment or clinical privileges at any healthcare facility while under investigation for disciplinary action while patient care is under review or investigation of disciplinary action or in order to avoid any disciplinary measures? 8. Have you ever been the subject of an external review instituted by another healthcare facility? 9. Do you require a reasonable accommodation to safely and competently exercise the clinical privileges and perform the duties and responsibilities of the medical staff appointment that you are requesting? 10. Have there ever been allegations, conviction or challenges of substance abuse or chemical dependency in New Jersey or elsewhere? 11. Have you ever been or are you being investigated by any governmental agency or been charged with a violation of federal, state, or local law (other than minor traffic violations)? 12.. Have there ever been any findings against you pertinent to a violation of patient rights? 13. Have you ever been the subject of an individual focused review required by NJ PRO or a similar agency? 14. Has your participation as a provider of services under Medicare, Medicaid, other insurers or any third party programs ever been voluntarily or involuntarily limited, suspended, restricted, modified, revoked or sanctioned? 15. Have you ever been the subject of a report(s) made by any other healthcare agency to DCA (Division of Consumer Affairs)? Initials: Yes Yes No No

5 16. Have you ever been removed or sanctioned by a managed care organization for reasons of clinical incompetence or professional ethics or behavior? VI. Medical Malpractice Insurance 1. Do you presently have any active and/or past malpractice claims, suits, summons and Yes No complaints, settlements or arbitration proceedings involving your professional practice filed, currently pending or settled in this state or any other state within the past five years? If yes, please attach specifics for each case on page 6 of application. Include the following information: Date of alleged occurrence Date suit or claim was initiated Name and location of the court Names of parties Description of the nature of the claim Current Status Amount of award (if applicable 2. Have you ever been denied professional liability insurance or has your coverage in this Yes No state or elsewhere been surcharged, suspended, terminated or canceled? If yes, please provide specifics on a separate page. 3. Are you currently insured by UMDNJ? Yes No 4. Do you currently have any other Malpractice Professional Liability Insurance (besides UMDNJ)? Carrier Name & Address: Policy Number: Yes No For Voluntary Faculty Please provide current insurance certificate listing University Hospital as certificate holder and; 5. Proof of professional liability coverage in the amount of $1 million per claim/$3 million per aggregate annually. If not UMDNJ, the Certificate must list University Hospital as certificate holder. Yes No VII. I affirm that no health problems exist that could affect my ability to perform the privileges requested, with or without reasonable accommodation. Last PPD/Chest X-ray/Exempt VIII. Continuing Medical Education: The By-Laws and Rules and Regulations of The University Hospital require that the hospital maintain files for the physicians on Continuing Medical Education Hours (CME s). All Providers who have an appointment to the Medical Staff at The University Hospital must submit their CME certificates or a primary source summary of their CME activity for the past two years. MD s & DO s Proof of CME as required by the New Jersey State Board of Medical Examiners for biennial registration (see cover sheet)> Adjunct Staff, the requirements are outlined by their board, i.e., NCCPA, AANC, etc. Dental Medicine and Podiatry requirements are outlined by their Board. OR You may attach a copy of the AMA Physician s Recognition Award Attached are copies of the CME certificates (as stated above) Attached is a copy of the PRA Initials: - 5 -

6 IX. Request for Reappointment to the Medical Staff Your signature on this application signifies that you agree to the following conditions of reappointment to the medical staff of The University Hospital. I have the burden of producing adequate information as requested by The University Hospital, for proper evaluation of my professional training, experience, clinical competence, ethics and other qualifications. I agree to assist, in every way possible, this medical staff and its representatives in gathering the information necessary to determine my qualifications, including but not limited to, appearing for interview(s), if requested. I attest that all of the information contained in this application is complete, true and accurate to the best of my knowledge, information and belief. I understand that any falsification, misstatement or omission of material facts, whether intentional or not, whether discovered prior to or after reappointment and/or privileges have been granted, will be sufficient cause for subsequent grounds for termination, denial or revocation of membership and/or privileges. I agree to report to The University Hospital any changes in physical and mental health status, including any impairment due to chemical dependency that would affect my ability to perform the privileges granted. I agree to report to The University Hospital any changes in staff membership status in other hospitals or health care facilities during this two year appointment. I acknowledge that I have read and agree to be bound by the By-Laws, Rules and Regulations of the Medical Staff of The University Hospital. I agree to notify The University Hospital within 30 days, if I receive notification that an Adverse Action Report of Medical Malpractice Payment Report has been filed on me with the National Practitioner Data Bank. CONFIDENTIALITY STATEMENT: In recognition of the confidential nature of patient records and/or employee data to which I may have access, either as part of my duties at UMDNJ-The University Hospital or for other reasons, I understand and will comply with the following: o I will not misuse or disclose any information without proper authorization, or alter patient or personnel records. I will not discuss patient or employee information except as it relates to my job. o I will not permit any other individual to use my information Systems password to gain access to the above mentioned information. I am responsible for and all information entered into the computer system under my user ID and password. I will report problems related to my password/system access to a person in authority. I will request modification to my system password if I suspect that another individual has gained access to my personal identification information. o I will file written/printed information in a secure place and/or dispose of it with proper regard for privacy and confidentiality. o I will not access, report on, or extract information that is not consistent with my normal job functions and responsibilities. o o I will not leave a secured computer application unattended while signed-on. I recognize that a violation of the above conditions may constitute grounds for disciplinary action, up to and including termination of employment, privileges or appointment. Violation of this policy by outside affiliates may constitute grounds for termination of all contractual relationship or other terms of affiliation between the outside affiliate and UMDNJ-The University Hospital. If accepted for medical staff appointment, I agree and pledge to conduct my professional activities in The University Hospital and elsewhere in accordance with the highest ethical traditions. In this connection, I agree to provide continuous care and supervision of my patients, refrain from delegating the responsibility of diagnosis and care of patients to a medical or dental practitioner who is not qualified. I will refrain from fee splitting and other inducements relating to patient referrals. I also agree to accept committee service. I will cooperate with The University Hospital in maintaining Joint Commission accreditation, as well as continuance of The University Hospital s operating certificate issued to The University Hospital. Initials: - 6 -

7 X. Professional History Inquiry: Please check the appropriate box or list the name(s) and address of any hospital or healthcare facility in the State of New Jersey or elsewhere at which you have/had privileges, association, employment or practice within the past FIVE YEARS: [ ] NONE Facility From/To Facility From/To Robert Wood Johnson UH Hackensack University Hospital Overlook Hospital Clara Maass Medical Center Holy Name Hospital Columbus Hospital: Other: Facility Name: Beth Israel Medical Center- Newark St. Barnabas Medical Center East Orange Hospital Veterans Affairs East Orange From/To/Rank Facility Address: City: State: Zip: Facility Name: From/To/Rank Facility Address: City: State: Zip: Facility Name: From/To/Rank Facility Address: City: State: Zip: XI. Licensure NJ License: Number Expiration CDS: DEA: Other: Initials: - 7 -

8 MALPRACTICE CLAIMS(S)/SUIT HISTORY LAST FIVE YEARS Addendum to Reappointment Application Please make additional copies if needed Name of Claimant: Date of Incident: Date Lawsuit Filed: Name of Court and Case #: Brief Description of Allegation: Status of Case (with reference to your involvement): Name of Insurance Company: Name of Claimant: Date of Incident: Date Lawsuit Filed: Name of Court and Case #: Brief Description of Allegation: Status of Case (with reference to your involvement): Name of Insurance Company: NONE [ ] Initials: - 8 -

9 AUTHORIZATION TO RELEASE INFORMATION I present this application and arrange for the submission of other information as part of the credentialing process in the expectation that the information will only be used for the medical staff credentialing, peer review and quality improvement activities. I agree to the communication of information pertaining to my professional qualifications by and to this hospital and medical staff and other persons, hospitals, managed care organizations, other medical facilities, medical staff and/or training programs in jurisdictions in which I have trained, resided or practiced, and professional liability insurance companies and licensing authorities in any jurisdiction, for the present and continuing evaluation of my professional qualifications, including but not limited to, licensure, training, experience, competence, ability to perform privileges requested, character, conduct judgment, professional misconduct, and malpractice claims history. I hereby waive any confidentiality provisions concerning the information required to be provided to The University Hospital and other hospitals, and release from liability all those who, in good faith, review, act on, or provide information regarding any and all of the above. Print Name: Initials: - 9 -

10 CONSENT FOR RELEASE OF INSURANCE INFORMATION* By applying for reappointment to the to the medical staff, I hereby authorize Name of your professional liability carrier (INCLUDING UMDNJ): and its staff, to release to The University Hospital and its representatives information in respect to my medical malpractice history, including, but not limited to the number of pending malpractice actions, details of the case(s) and settlements or judgments. I also consent to the release of a copy of my professional liability certificate indicating the category of coverage and the release of information concerning the non-renewal, cancellation and change in policy limits, or added special limitations of such medical malpractice insurance. I hereby release from liability my professional liability carrier, its agents, employees and representatives for their acts performed in good faith and without malice in connection with releasing such insurance information, and I hereby consent to the release of such information. Print Name: Policy/Acct # *You may be required to obtain this information directly from your current carrier (except UMDNJ). Please call if you should require assistance. Initials:

11 FOR OFFICIAL USE ONLY: [ ] Initial Appointment [ X ] Reappointment Name of Applicant: Department/Division: Category: Temporary//Provisional Appointment Chairman s Signature & NPDB Query Credentials Committee Recommendation Appointment and Clinical Privileges Recommended Appointment and Clinical Privileges Not Recommended Appointment and Clinical Privileges Deferred Credentials Committee Chairperson s Chief of Staff Medical Executive Committee Recommendation Appointment and Clinical Privileges Recommended Appointment and Clinical Privileges Not Recommended Appointment and Clinical Privileges Deferred Medical Executive Committee Chairperson s Action by the University Hospital Board of Directors: Appointment and Clinical Privileges Recommended Appointment and Clinical Privileges Recommended Appointment and Clinical Privileges Recommended Representative, Board of Directors Signature & Meeting Action by the Board of Trustees: Appointment and Clinical Privileges Approved Appointment and Clinical Privileges Approved Appointment and Clinical Privileges Approved Representative, Board of Trustees Signature & Meeting CEO and President (or Designee) Initials: