Practice Name: Brief overview of your intended scope of practice at Anna Jaques Hospital:

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1 Medical Staff Application for Initial Appointment Supplemental Page Introduction (to be presented to the Credential Committee): Practice Name: Brief overview of your intended scope of practice at Anna Jaques Hospital: Health Status: (* please note: all yes answers require an explanation on a separate sheet) 1. Have you ever been a habitual user of a DEA classified drug, illicit drug or alcohol? Yes No 2. Have you ever received treatment for drug or alcohol abuse? Yes No 3. Have you ever been physically or mentally impaired such that it adversely affected your ability to practice medicine? Yes No Medical Staff Category/Department: Please designate the medical staff category to which you are applying: Active Staff Courtesy Staff Affiliate Staff Telemedicine Associate Clinical Staff (DDS, PA, NP, CRNA, CNM, APRN, RNCS) Support Staff (DA, OTC, OTR, LCSW, LMHC, RNFA) Please designate the department to which you are requesting privileges in: Anesthesia Emergency Medicine Internal Medicine/Family Practice Obstetrics/Gynecology Pathology Pediatrics Psychiatry Radiology Surgery Practice Start Date: Please indicate the date you will start your professional practice:

2 MEDICAL INFORMATION FORM NAME: ADDRESS: CURRENT HEALTH STATUS: DATE OF LAST EXAM: SIGNIFICANT FINDINGS: Name, address and phone no. of the physician and/or institution(s) where performed: Dates and causes of all hospitalizations for the past five (5) years: Signature Credentialing/MED INFO FORM.doc Date

3 Health Care Provider Immunization for Medical Staff DO NOT RETURN THIS FORM TO THE MEDICAL STAFF OFFICE Please call the AJH Occupational Health Service to schedule your screening. Bring this form and documentation with you. All documentation must be provided before final clearance for credentialing can be completed. Occupational Health Service 24 Morrill Place, Amesbury, MA Phone: Fax: NAME: DOB: Please print clearly Specialty Please print clearly Documentation with facility name and dates must be provided for the following: 1. TST: The 2 step method is being used for all new hospital staff. #1 #2 The TST is not contraindicated for persons who have been vaccinated with BCG. I have had a positive TST and a negative chest x-ray. (results included) I have completed the Positive TST questionnaire. 2. MMR: Born before 1957: documented proof of one (1) dose of MMR or a positive blood titer. Born 1957 or after: documented proof of two (2) doses of MMR or a positive blood titer. If working on Pediatrics and/or the Birth Center a positive titer is the only acceptable proof of immunity for Measles, Mumps or Rubella. 3. Chicken Pox (Varicella): I have a positive history for chicken pox * * If working on Pediatrics or the Birth Center a positive titer is the only acceptable proof of immunity. I have not had the chicken pox. A Varicella titer needs to be drawn to determine immunity. 4. Fit test: If you will be expected to wear an N95 mask during your work at AJH then a Fit Test for a 3M N95 mask must be done. I will not be wearing an N95 mask. If you need a titer drawn it can be drawn either in OHS or at the hospital lab at no charge to you. You must register with OHS prior to going to the lab by calling

4 MEDICAL STAFF COVERAGE FORM Name: Name of Group Practice: Specialty: CONTACT PHONE NUMBERS: Please identify in the box the order in which you prefer to be contacted. (i.e., 1.office, 2 cell, 3. beeper) List a minimum of two (2) alternative numbers in addition to your office number. **Note: The Medical Staff Policy states that if there is no answer after 20 minutes you will be contacted via the alternative numbers on this preference list. Office: Fax: Cell Phone: Home: Pager: COVERING PHYSICIANS WITH CONTACT INFORMATION: Please document regularly scheduled time out of office. (i.e., Tuesday-off etc.) cc: Switchboard & Security

5 Insurance Company Name Authorization to Release Claim History And Coverage Verification Form Printed Name of Provider: Name of Organization: Anna Jaques Hospital Medical Staff Services 25 Highland Avenue Newburyport, MA MA Medical License Number or Social Security #: NPI# Policy# Mail the Loss History and Coverage Verification Report to: Name of Organization: Anna Jaques Hospital Medical Staff Services 25 Highland Avenue Newburyport, MA I authorize the release of my coverage and claim history to the organization listed above. Signature of Provider (no stamps are accepted) Signature Date (required) /th reference: ProMutual Template (

6 PHYSICIAN ACKNOWLEDGMENT STATEMENT NOTICE TO PHYSICIANS CHAMPUS 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 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. SIGNATURE: PRINTED NAME: DATE: Credentialing/champus form.doc

7 PHYSICIAN ACKNOWLEDGMENT STATEMENT 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. SIGNATURE: PRINTED NAME: DATE: Credentialing/:medicare form

8 DEA NUMBERS AND SIGNATURES In order to verify the signature of a staff physician on a prescription, the pharmacy requests that you sign below and submit your controlled substance registration number. In doing so, the likelihood of a fraudulent prescription being filled will be reduced significantly. SIGNATURE: PRINTED NAME: DATE: CONTROLLED SUBSTANCE REGISTRATION #: Credentialing/DEA form.doc

9 PHYSICIAN ACKNOWLEDGEMENT OF HIPAA PRIVACY TRAINING Anna Jaques Hospital upholds all the principles of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule and expects all Hospital employees and Physicians to be completely educated in these provisions in order to protect patient privacy at all times. This signed acknowledgement represents that HIPAA training has been provided and understood and that every effort will be made to follow all the provisions of this rule as part of the care provided to patients at Anna Jaques hospital. The full text of the HIPAA Privacy Rule can be found at 45 CFR (b) and 45 CFR (a)(2); Note this does not cover disclosure of psychotherapy notes which require a patient s written authorization. SIGNATURE: PRINTED NAME: DATE: HIPAAmded form

10 Anna Jaques Hospital Confidentiality and Security Agreement (Medical Staff Edition) You, the undersigned, have requested permission to access certain computer systems in order to efficiently provide medical services to patients at Anna Jaques Hospital. Confidential patient and sensitive business information is this Hospital s most valuable information asset residing on computer systems which are supported by Anna Jaques Hospital. The privacy of the Hospital s confidential patient and sensitive business information depends on the protection of this information against theft, destruction or unauthorized disclosure to outside interests. In order to be granted access, you must understand and agree to be bound by the information security policies in effect for Anna Jaques Hospital. Therefore, in consideration of being allowed access to the Hospital s software systems and patient records, I, the undersigned, hereby agree to the following provisions: I will only access software systems to review patient records when I have that patient s consent to do so. By accessing a patient s record, I am affirmatively representing to Anna Jaques Hospital at the time of each access that I have the requisite patient consent to do so, and Anna Jaques Hospital may rely on that representation in granting such access to me. I will insure that only appropriate personnel in my office will access the Hospital software systems and patient records and I will annually train such personnel on issues related to patient confidentiality and access. I will accept full responsibility for the actions of my employees who may access Anna Jaques Hospital software systems and patient records. I will not operate or attempt to operate the Hospital s computer equipment without specific authorization. I acknowledge receipt of, and I hereby agree that I will abide by, the Information Systems Physician Access Policies. I hereby agree that I will also abide by all current and future information security policies for Anna Jaques Hospital. I will maintain assigned passwords or access methods that allow access to computer systems and equipment in strictest confidence and not disclose a password or access method to anyone, at any time, for any reason, as I acknowledge this increases the possibility of accidental disclosure. I will contact Anna Jaques Hospital s Information Systems Department immediately and request a new password if mine is accidentally revealed. I will not disclose any portion of the Hospital s computerized system to any unauthorized individuals. This includes, but is not limited to, the design, programming techniques, flow charts, source code, screens and documentation created by Hospital or outside sources. I will not disclose any portion of a patient's medical record except to a recipient authorized by the patient to receive that information. I will report activity that is contrary to the provisions of this agreement to Anna Jaques Hospital s Information Service Department. I understand that failure to comply with the terms of this Agreement and the authorization to access information/software systems may result in formal disciplinary action up to, and possibly including, the termination or cancellation of this Agreement and discipline by the Hospital s Medical Staff. Physician/AHP Signature Physician/AHP Group/Office Date Physician/AHP Printed Name

11 Fax Number Verification For Diagnostic Test Result Reporting HIPAA Requirement Date: / / Requested by: Please FAX this form as soon as possible to: Thank you You have requested radiology and/or laboratory results for a patient to be faxed to your office. It is the policy of this hospital to fax confidential patient results only to those fax numbers which have been verified. Failure to return this form will prevent results from being faxed to your office. Please confirm below the fax numbers where you would like radiology and laboratory results faxed and sign below. Radiology Wet Reads Test Results for: Fax Number to be used Radiology Results Laboratory Results MD Office/Facility: Location: Signed: Date: FOR DEPARTMENTAL USE ONLY FAX TO MEDICAL STAFF OFFICE X1215: YES NO DATE: FAX TO LABORATORY X1103: YES NO DATE: FILE IN LIS Disclosures for Treatment, Payment and Health Care Operations (TPO) 45 C.F.R. Part Anna Jaques Hospital staff may disclose protected health information, without an individual s Authorization, or without the necessity for an opportunity to agree or object for Anna Jaques Hospital s own treatment, payment or health care operations of an individual. *****CONFIDENTIALITY NOTICE***** The documents accompanying this transmission may contain confidential health information that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party unless required to do so by law or regulation and is required to destroy the information after its stated need has been fulfilled. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or destruction of these documents. If you have received this transmission in error, please contact the above number

12 ADMINISTRATIVE POLICY AND PROCEDURE MANUAL TITLE: For-Cause Drug/ETOH Test Policy ATTACHMENT B AUTHORIZATION TO USE AND/OR DISCLOSE PROTECTED HEALTH INFORMATION Pursuant to the For-Cause Drug/ETOH Test Policy of the Anna Jaques Hospital Medical Staff, I have decided to voluntarily submit to a requested medical assessment which may include a drug and/or alcohol screen by AJH Department of Occupational Health Services and/or Laboratory. I have also been informed and am aware that the results of this medical assessment and related tests might constitute Protected Health Information (PHI) for purposes of the federal Health Insurance Portability and Accountability Act of 1996, and the regulations issued thereunder, both as amended from time to time, including without limitation by the federal Health Information Technology for Economic and Clinical Health Act (Public Law 111-5, the HITECH Act ), all together referred to as HIPAA, and may need to be released to certain bodies or individuals at Anna Jaques Hospital, which is a Covered Entity under HIPAA. I hereby authorize the use and/or disclosure of the following described information: the results of this medical assessment and of any and all related tests. The name of the persons authorized to make the use and/or disclosure: Anna Jaques Hospital. The name of the persons to whom Anna Jaques Hospital may make the use or disclosure: any or all of the following bodies or persons at Anna Jaques Hospital: Medical Executive Committee, Physician Health Committee, Performance Improvement Committee, Patient Care Assessment Committee, Credentials Committee, President of the Hospital, President of the Medical Staff, my Department Chief, my Assistant Department Chief. The purpose of the use and/or disclosure of the PHI described above is: implementation of the For-Cause Drug Test Policy of the Anna Jaques Hospital Medical Staff, and of any Medical Staff or Hospital reviews or actions that might follow the results of the medical assessment and related tests. Expiration Date: This authorization shall, if not sooner revoked by me, expire upon termination of my membership on the Medical Staff of Anna Jaques Hospital. I am on notice and understand that I have the right to revoke this authorization in writing at any time; however, I understand that my revocation will not affect uses or disclosures of the PHI made, or other actions taken, by Anna Jaques Hospital or its Medical Staff prior to the time of such revocation. I am on notice and understand that Anna Jaques Hospital may not condition treatment, payment, enrollment or eligibility for benefits upon whether I sign this authorization. I am on notice and understand that there is the potential for the information disclosed pursuant to this authorization to be subject to redisclosure by the recipient(s) and no longer protected by the applicable provisions of HIPAA. Signed: PRINT NAME: Date: