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

Transcription

1 DMC Corporate Medical Affairs/CVO 4707 St. Antoine, Ste. E510/Hutzel Building Mail Code 522 Detroit, Michigan Phone Fax Dear Applicant: Thank you for your interest in joining The Detroit Medical Center (DMC). We are pleased to offer you a more efficient and convenient way to complete and submit your application for membership and privileges. DMC now utilizes the CAQH Universal Provider Datasource online application. Please read the information below to assist you in submitting the on-line application and the supplemental forms. Once you have submitted all necessary documentation, the DMC Central Verification Office (CVO) will periodically contact you and provide an update on the processing of your application. If we are experiencing difficulty in obtaining any of the required verifications and references, we will ask your assistance in facilitating. Upon completion of the credentialing verification process, your application and supporting documentation will be forwarded to the appropriate Department to which you are applying for consideration and recommendation. Final action with respect to your application is the responsibility of the governing body of the DMC. You will be notified upon that final action. If you have any questions, please contact us at We look forward to receiving your completed application. Sincerely, Mary l. Merity, CPCS Mary L. Merity, CPCS Corporate Director DMC Corporate Medical Affairs

2 IMPORTANT CREDENTIALING INFORMATION Thank you for requesting an application for membership and privileges at the Detroit Medical Center (DMC). The DMC is committed to the highest quality of care and patient safety. In support of this goal, please review the following important information. I. BOARD CERTIFICATION REQUIREMENTS Effective July 1st, 2009, all applicants to the DMC Medical Staff must be board certified, or in the active certification process with board certification attained within five (5) years of completion of formal training. Board certification must be in the specific practice area in which clinical privileges are requested and by a recognized certifying board, i.e. American Board of Medical Specialties, American Osteopathic Association, American Dental Association or the American Board of Podiatric Surgery. Please note that the board certification requirements by individual clinical departments may be more stringent. If so, the department s requirements supersede the DMC minimum board certification requirement. Board certification must be maintained in those specialty boards that are time-limited. II. MEDICAL STAFF CATEGORY DETERMINED BY LEVEL OF ACTIVITY To maintain quality patient care and safety, the DMC must be able to review and evaluate a physician s clinical and professional performance. This requires active utilization of the DMC hospitals/ambulatory centers and meeting the activity requirements defined by the clinical department. If you are only planning to refer patients and/or anticipate minimum DMC patient volume, you may wish to request Affiliate status, Membership only (with no clinical privileges). This affiliation will allow you to electronically track your referred patients and participate in other WSU/DMC opportunities without having to meet certain medical staff requirements. IF YOU HAVE ANY QUESTIONS OR WISH ADDITIONAL INFORMATION, PLEASE CONTACT DMC CENTRAL VERIFICATION OFFICE AT

3 Central Verification Office (CVO) INSTRUCTIONS Completing the DMC Credentialing Application Process 1. ACCESS: DMC utilizes the CAQH provider credentialing application that is accessed via the Internet. If you are a registered user, click on This will take you to the CAQH website to complete/update the provider application. Click on Universal Provider DataSource. Then click on CAQH Provider Credentialing Application and follow the instructions. Once the application is complete, please ensure the Detroit Medical Center has been added as an authorized healthcare organization. If you are not registered with CAQH, please contact the DMC Central Verification Office to facilitate this process. 2. COMPLETE: Complete the following DMC hospital-specific documents: DMC Supplemental Application DMC Authorization for Release of Information/Liability form DMC Appointment and Membership Desired form DMC MPRO Medicare Statement DMC CME Attestation form DMC Delineation of Privileges form. Please review form carefully and note any extra documentation that may be required for your particular specialty, i.e., surgical summary, evidence of additional training, 2 year surgical case summary for pediatric surgical privileges, etc. DMC Health Access Center (if applicable) DMC Auto Fax Enrollment form (if applicable) 3. SUBMIT: Submit the following to the DMC Central Verification Office: DMC supplemental application and documents listed in #2 above. Copy of government-issued photo identification (driver s license). 1.5 x1.5 color photo. You may provide either a passport photo or a clear photo with a head shot. You may also e- mail a digital photo to dmccredentialingonline@dmc.org. $ DMC application fee. (For membership only, application fee is $200.) Make check payable to The Detroit Medical Center. Proof of U.S. citizenship (VISA, Green Card), if applicable. Proof of current and past professional liability insurance. For current insurance, documentation must state that this coverage extends to your practice within the DMC facilities. DMC policy mandates a minimum of $100,000/$300,000 coverage. Board certification certificates. Internship, residency program(s), and fellowship program(s) certificates of completion. Written explanation of any gaps in education/training and work history greater than 30 days. ACLS/BLS certificates, as required. Evidence of compliance with mandatory Tuberculosis Evaluation (within the last 12 months).

4 DMC SUPPLEMENTAL APPLICATION A. PERSONAL INFORMATION Applicant Full Name: Marital Status: Ethnicity (optional): Applicant Personal Spouse s Name: Citizenship: If not a US citizen, do you have authorization to work in the US? Yes No In addition to the three (3) professional peer references provided on your CAQH application, please provide two (2) additional references, preferably within your clinical specialty. These references may not be your residency director, fellowship director, current clinical department chairperson, current partners or associates in your practice. Name: Specialty: Address: Phone: City, State, Zip: Fax: address: Name: Specialty: Address: Phone: City, State, Zip: Fax: address: B. OFFICE PRACTICE INFORMATION 1. Type of practice Corporation Partnership Solo Hospital Based Hospital Employed Institution Rural/Federal Qualified Health Clinic 2. Do all offices have: Internet access Electronic medical record keeping system Capability for electronic billing billing code: 3. Do you have any investment or other financial interest in any health care delivery organization (i.e., home health care, laboratory, managed care organization, etc.)? Yes No If yes, please describe: 4. List financial partners:

5 C. DISCLOSURE INFORMATION Please provide a detailed explanation on a separate sheet for any YES responses to the questions below. Have any of the following been or are currently in the process of being denied, revoked, not renewed, suspended, limited, restricted, reviewed, placed on probation, or placed under other disciplinary action, either voluntarily or involuntarily? YES NO Employment by any hospital or institution? Professional society membership? At any time, have you ever been: YES NO Convicted of any criminal offense in any jurisdiction Convicted of a misdemeanor relating to a health profession, or received probation without a verdict, disposition in lieu of a trial, or an accelerated rehabilitation disposition of felony charges in any state, territory or country? Have you ever, at any time, or are you currently: YES NO Under audit by a Health Care Agency (i.e., Medicare, Medicaid, MDCH, or any insurance) Under indictment for any crime? The subject of an investigation by any private, federal or state health insurance program or state, territory or country licensing board? The subject of any adverse action reports to a state or federal agency? Sanctioned by a government program or agency for any reason? Have you ever, at any time, either voluntarily or involuntarily: YES NO Withdrawn your application for medical staff membership at any facility? Withdrawn your request for any clinical privileges at any facility? D. ATTESTATION STATEMENT I attest that the information provided in this supplemental application is true and complete to the best of my knowledge. Signature: Date:

6 DMC AUTHORIZATION FOR RELEASE OF INFORMATION/LIABILITY Full Name (PLEASE PRINT) Date For purposes of this authorization, hospital(s), means The Detroit Medical Center ( DMC ), each Detroit Medical Center hospital(s), DMC CARE (DMC owned and/or affiliated managed care plans), any entity for which DMC performs delegated credentialing or recredentialing services DMC Professional Liability Program ( DMC PLP ), DMC Physicians Group to which I am applying for medical staff(s) privileges and/or membership and includes members of its board of trustees, its medical staff(s), its administration and any other employee or agent of the hospital(s) having responsibility for collecting information, evaluating my competence and qualifications; or acting upon this application; Information includes all records, documents, medical records, and otherwise privileged or confidential information; Competence and qualifications including clinical ability, professional ethics, character, physical and mental health, emotional stability, ability to work with others, and moral and other qualifications for medical staff appointment(s), reappointment(s) and clinical privileges; and third-parties include without limitation (i) other hospitals and their trustees, directors, employees or agents, medical staffs and associations, (ii) licensing boards, (iii) other organizations and persons concerned with provider or physician performance or the quality and efficiency of patient care, (iv) malpractice carriers and other providers of professional liability coverage, and (v) the National Practitioner Data Bank. AUTHORIZATION By applying for appointment or reappointment to the medical staff(s) of the hospital(s): A I authorize the hospital(s) to consult with all third parties with whom or which I have been associated concerning my competence and qualification, or with any third parties who may have information bearing thereon (including malpractice carriers and defense counsel), and to receive and utilize any information received in response thereto, and to inspect any and all information which may be material to my qualifications and competence and I hereby release all third parties who provide information to hospital(s), from any and all liability for the transmittal in good faith and without malice of any information bearing on my qualifications and competence; in connection with any such request for but not limited to appointment and reappointment of medical staff(s) privileges and/or membership; B If the hospital(s) seek to gather information relating to my competence and qualifications from current or prior professional liability claims in which I am or was represented by counsel, I hereby waive any attorney-client privilege, whether such privilege is granted by the statues or case law of the State of Michigan or any other jurisdiction, and I hereby release any attorney or other person from any and all liability in connection with the release of such information to the hospital(s). C I authorize and release the hospital(s) from all liability for forwarding to any other hospital(s) or entity to which I may apply for privileges any information concerning me, my competence and qualifications, as hospital(s) has at the time of my application for appointment or hereafter acquires in accordance with the medical staff(s) bylaws; D I authorize and release the hospital(s) from all liability for forwarding to any affiliate of the hospital(s) copies of my application for appointment and/or membership including all attachments, and if appointed to the medical staff(s) of hospital(s), any and all information regarding any proceedings or action taken by hospital(s) regarding appointment, reappointment, and/or clinical privileges (including the granting, extension, reduction, suspension or termination thereof), utilization review of quality assurance information and any other information including without limitation information received from the National Practitioner Data Bank concerning my competence and qualifications which hospital(s) has at the time of my application for medical staff appointment(s) or hereafter acquires; E I release from all liability the hospital(s) and all third parties from any statements made or any action taken in good faith and without malice in connection with this application or any other applications made simultaneously herewith, and in connection with any proceedings for reappointment, and/or clinical privileges (including the granting, extension, reduction, suspension or termination thereof), or in connection with a transfer to any other department or section of the medical staff(s), or in connection with any other form of review of my qualifications and competence or of my professional practices in the hospital(s) conducted in accordance with the medical staff(s) bylaws; UNDERSTANDING & COMMITMENT F I express my willingness to appear for interviews with all individuals and before all committees of the medical staff(s) which may be requested of me by hospital(s) in regard to my application. G I acknowledge that I have received, or been given access to, the bylaws of the medical staff(s) and articles of incorporation and bylaws of the hospital(s) to which I have applied. H I agree to abide by the bylaws of the medical staff(s), and for clinical privileges, and by such rules and regulations as the medical staff(s) or any department thereof may from time to time enact, as the same may be amended from time to time. If I am granted appointment or clinical privileges at the hospital(s), I agree to conform to the then current articles of incorporation and bylaws of the hospital(s), their policies, including the DMC Code of Conduct. Further I agree to complete compliance and sexual harassment prevention training required during the term of my appointment. Whether or not I am granted appointment or clinical privileges at the hospital(s), I agree to be bound by the Medical Staff and hospital(s) rules and policies in all matters relating to the consideration of my application for appointment and reappointment; I If I am granted staff appointment(s) and clinical privileges, I agree to abide by all ethical requirements of the bylaws of the medical staff(s), including, without limitation, the requirement to provide for continuous care and supervision of my patients. I pledge to maintain the highest ethical standards and to abide by the codes and principles of ethics of my state and national professional societies and associations.

7 I further agree to abide by the professional practice act of the State of Michigan under which I am licensed. I pledge to maintain the standards of, and meet the requirements of, the Michigan Department of Public Health and the Joint Commission on Accreditation of Healthcare Organizations, so that hospital(s) may receive full licensure and accreditation at all times. I agree that I will not participate in any form of fee splitting. In complying with this principle, I understand that I am not to collect fees for others referring patients to me, nor permit other physicians or surgeons to collect fees from me; J I agree that the decision of the board of trustees on this or any other application or proceeding concerning my appointment(s) or privileges shall be final and binding; K I agree to keep the hospital(s) informed of the status, and any changes in status, of professional liability coverage and professional liability claims that may from time to time be brought against me. I also agree to keep the hospital(s) informed of any adverse actions taken or proposed to be taken against me by peer review organizations, the state licensing board, and other hospital(s) or health care entities with which I am also affiliated; L I agree that, in connection with the health history requested in this application an in any situation in which my physical or mental health is at issue, I will waive, in favor of the hospital(s), its agents and employees, and all members of its board of trustees, administration and medical staff(s), any medical or physician-patient privilege relating to such physical or mental condition, whether such privilege is granted by the statues or case law of the State of Michigan or any other jurisdiction, or is granted by the provisions of federal regulations relating to alcohol and drug abuse. I do agree to release, and I do hereby release any physician, hospital(s) or other person or entity providing such information, from any and all liability for the release of any information which, except for such waiver, would be privileges and confidential; I further agree to facilitate the release of such information by providing appropriate release and authorization forms; I understand that, in the event that any physician or hospital(s) continues to refuse to provide such information, the hospital(s) shall give no further consideration to my application for a staff appointment(s) or membership, and privileges, if previously granted, shall be terminated; M I further specifically acknowledge that the provisions of the medical staff(s) relating to confidentiality and release from liability are express conditions of my application for, and acceptance of, medical staff appointment(s) and the continuation of such appointment(s) and to my exercise of clinical privileges; N I understand and agree that I, as an applicant for a medical staff appointment(s), have the burden of producing adequate information for proper evaluation of my competence and qualifications, and for resolving any doubts about such competence and qualifications; O I understand that I am obligated to disclose in the above application all information which would be material to my being granted a medical staff appointment(s) of this hospital(s), and further understand that any misstatement(s) in, or omission(s) from, this application will constitute cause for denial of appointment, reappointment, or cause for summary dismissal from the medical staff(s); P I understand that under the Health Care Quality Improvement Act of 1986, as amended, the hospital(s) are required to query the National Practitioner Data Bank and to include the response from that agency in the materials to be reviewed by persons involved in the credentialing process. I also understand that the hospital(s) are required by law to advise the National Practitioner Data Bank of any adverse action which it takes with regard to a physician or dentist s application for staff privileges (i.e. active, courtesy), application for increase of privileges, if the hospital(s) decisions are based upon a physician or dentist s level of competency or upon any act of improper professional conduct. I understand that the hospital(s) have elected to comply with the voluntary or permissive reporting of any action taken by the hospital(s) with regard to applications of licensed health care practitioners other than physicians and dentists. For purposes of Health Care Quality Improvement Act an adverse action includes, but is not necessarily limited to a decision to deny privileges, or to grant privileges at a lower level than applied for, where the decision is based upon an evaluation or competence or an act of improper professional conduct. I further understand that the hospital(s) may query and/or report to any other data bank or agency which may be required by Federal or State law, and include responses from such queries in the materials to be reviewed by persons involved in the credentialing process. Q In the event I am applying to participate in DMC owned and/or affiliated managed care plans, I understand that references in this Authorization for Release of Information form to medical staff appointment(s) or reappointment(s) to the medical staff(s) shall be deemed to mean designation as a participating member of DMC owned and/or affiliated managed care plans. I understand, unless otherwise indicated, any DMC employed and/or faculty physician will be considered as applying for membership in DMC owned and affiliated managed care plans. I also understand that references to medical staff(s) bylaws shall be deemed to mean the DMC owned and/or affiliated managed care plan participation and/or appointment standards, whether in the form of medical staff(s) bylaws, rules, regulations or otherwise; and R I understand that the term Detroit Medical Center Hospitals shall mean and include Children s Hospital of Michigan, Detroit Receiving Hospital and University Health Center, Harper Hospital, Huron Valley Sinai Hospital, Hutzel Hospital, Rehabilitation Institute of Michigan, and Sinai-Grace Hospital, any successors and assignees of the foregoing, and any other designee of The Detroit Medical Center for credentialing for the purposes of managed care plans. I hereby represent that all information submitted by me in this application is true and complete to the best of my knowledge and belief. Signature of Applicant Date JCC (revised)

8 APPOINTMENT AND MEMBERSHIP DESIRED MEDICAL STAFF CATEGORY Please check one: ACTIVE AFFILIATE AFFILIATE/Membership Only No Clinical Privileges HOSPITAL MEMBERSHIP AND/OR PRIVILEGES Please check all hospitals where you intend to practice (this does not restrict privileges and you may add hospitals at any time upon notification to DMC Corporate Medical Affairs. You must also indicate which hospital will be your primary hospital. HOSPITALS Children s Hospital of Michigan Detroit Receiving Hospital Harper University Hospital Huron Valley Sinai Hospital Hutzel Women s Hospital Rehabilitation Institute of Michigan Sinai Grace Hospital DMC Surgical Hospital Berry Surgery Center PRACTICE LOCATIONS (Check all hospitals you wish to practice at) PRIMARY HOSPITAL (Select only one) MANAGED CARE PARTICIPATION Practitioners approved for DMC staff privileges will also receive DMC Managed Care privileges as part of the credentialing process. DMC Managed Care privileges will allow you to be enrolled in DMC Affiliated Managed Care Health Plans. Upon approval of DMC Managed Care privileges, practitioners will receive a Health Plan Enrollment packet. The packet will be sent to the mailing address indicated on your application, unless we are notified otherwise. Are you currently enrolled in any Health Plans? Yes No Are you affiliated with a Hospital Organization or Physician Organization Group? Yes No If so, please list This is a confidential professional/peer review and quality improvement document of the DMC. It is protected from disclosure pursuant to one or more of the provisions of MCL , MCL , MCL , MCL , MCL , and MCL a and other state and federal laws. Unauthorized disclosure or duplication is absolutely prohibited

9 Name: Address: City, State, Zip Code: In accord with 42 Code of Federal Regulations (CFR) we are providing the following: NOTICE TO PHYSICIANS Medicare payment to hospitals is based in part on each patient s principal and secondary diagnoses and the major procedures performed on the patient, as attested to by the patient s attending physician by virtue of his or her signature in the medical record. Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal funds, may be subject to fine, imprisonment, or civil penalty under applicable Federal laws. (42 CRF ) Your acknowledgment of receipt of this notice must be kept on file at the Detroit Medical Center for its hospitals: Children s Hospital of Michigan, Detroit Receiving Hospital, Harper University Hospital, Huron Valley-Sinai Hospital, Hutzel Women s Hospital, Rehabilitation Institute of Michigan, and Sinai-Grace Hospital. PLEASE SIGN THIS LETTER AND RETURN IT WITH YOUR APPLICATION PACKET. If you have any questions, please contact DMC Medical Affairs at (313) RECEIVED: Signature Date This is a confidential professional/peer review and quality improvement document of the DMC. It is protected from disclosure pursuant to one or more of the provisions of MCL , MCL , MCL , MCL , MCL , and MCL a and other state and federal laws. Unauthorized disclosure or duplication is absolutely prohibited

10 CONTINUING MEDICAL EDUCATION ATTESTATION In applying for appointment/reappointment to the medical staff (s) of the Detroit Medical Center, I attest and affirm that: 1. I am in full compliance with the State of Michigan requirements for Continuing Medical Education (CME) hours; 2. I meet the DMC Medical Staff requirements for Compliance Education as provided by the DMC; 3. I further attest that the majority of my attendance at CME programs were directly related to my areas of practice; and 4. I agree to provide proof of attendance and program content upon request. I understand and agree that I, as an applicant for a medical staff appointment(s) or reappointment, have the burden of producing adequate information for the proper evaluation of my competence and qualifications, and for resolving any doubts about such competence and qualifications. I understand that any misstatement(s) in, or omission(s) from, this CME Attestation will constitute just cause for denial of appointment, reappointment, or become cause for discipline, up to and including summary dismissal from the medical staff(s) and represent that all information submitted by me in this application is true and complete to the best of my knowledge and belief. Print Name Signature Date This is a confidential professional/peer review and quality improvement document of the DMC. It is protected from disclosure pursuant to one or more of the provisions of MCL , MCL , MCL , MCL , MCL , and MCL a and other state and federal laws. Unauthorized disclosure or duplication is absolutely prohibited

11 TB COMPLIANCE The Occupational Health and Safety Administration (OSHA) and the DMC (policy 1 CLN 013) require annual tuberculosis (TB) evaluation for all healthcare professionals. Evidence of this annual evaluation must be submitted with your initial application packet and annually thereafter. Results of your TB evaluation must be current, within the last twelve (12) months. It must be documented when read, in millimeters of induration. Free TB (Mantoux) test may be performed at any DMC hospital Occupational Health Services (OHS) department. If you are PPD positive, documentation of a recent chest x-ray is required. Chest x- ray (PA and lateral view) may be performed at any DMC facility where diagnostic radiology services are available, and may be covered by your insurance. Recent conversion to positive PPD and/or positive PPD refusing isoniazid prophylaxis treatment will need chest x-ray s for two (2) consecutive years. Following two consecutive clear x-rays and annual evaluation is sufficient. Form for completion of this evaluation is available via OHS or DMC Medical Affairs. DMC Occupational Health Services sites are available to assist you with the required testing or evaluation. OHS Central Region, University Health Center 4K OHS Sinai-Grace Hospital, 6071 W. Outer Drive, One South/Express Care OHS Huron Valley-Sinai Hospital, 1 st Floor Please call for hours of operation or if you have any other questions related to your TB evaluation. THANK YOU! This is a confidential professional/peer review and quality improvement document of the DMC. It is protected from disclosure pursuant to one or more of the provisions of MCL , MCL , MCL , MCL , MCL , and MCL a and other state and federal laws. Unauthorized disclosure or duplication is absolutely prohibited

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