Doctors Hospital Allied Health Professional Application for Appointment

Doctors Hospital Allied Health Professional Application for Appointment Applying for the following job (please check): Allied Health Delineation of Privileges Allied Health Scope of Practice Category 1 Category 3? Urgent Care/Fast Track Physician Category 2? Certified First Assistant (CFA)? Certified Surgical Technician/Surgical Dental Asst. (CST)? Certified Nurse Midwife (CNM)? Medical Assistant? Certified Nurse Practitioner (CNP)? Privately Employed RN? Certified Nurse Specialist (CNS)? Radiology Technician? Certified Registered Nurse Anesthetist (CRNA)? Registered Nurse First Assistant? Physician Assistant (PA)? Rounding Assistant? Certified Neonatal Nurse Practitioner (CNNP)? Physician Delegated Prescriptive Authority ( PA s)? Prescriptive Authority (ANP s) of Application Applicant Name (Print) Social Security Number of Birth E-Mail Address ( ) ( ) Pager # Cell Office Address and/or Hospital Department City / State / Zip ( ) ( ) Office Office Fax Home Address City / State / Zip ( ) Home Collaborating Physician ( if privately employed) and/or Supervisor Name ( if employed by the Hospital): Preferable means of contact (check all that apply): Pager Cell E-Mail Hire date Approved: January 2009 Doctors Hospital Allied Health Professional Application Page 1 of 13

LIST ALL CURRENT HOSPITAL AFFILIATIONS Copy of Curricula Vita/Resume is NOT accepted as a substitute. Hospital Name Nature of Affiliation From to Hospital Name Nature of Affiliation From to Hospital Name Nature of Affiliation From to PROFESSIONAL EDUCATION Provide history, starting after High School, of all work, education and training including but not limited to military services, public health or business training. Copy of Curricula Vita/Resume is NOT accepted as a substitute. 1. Institution Month / Year Started Month / Year Completed Degree ( ) 2. Institution Month / Year Started Month / Year Completed Degree ( ) 3. Institution Month / Year Started Month / Year Completed Degree ( ) Approved: January 2009 Doctors Hospital Allied Health Professional Application Page 2 of 13

PREVIOUS EMPLOYMENT List employment since completion of training Copy of Curricula Vita/Resume is NOT accepted as a substitute. 1. ( ) Employer Name s of Employment: Month /Year Started Month / Year Complete Reason for Leaving 2. ( ) Employer Name s of Employment: Month /Year Started Month / Year Complete Reason for Leaving 3. ( ) Employer Name s of Employment: Month /Year Started Month / Year Complete Reason for Leaving 4. ( ) Employer Name s of Employment: Month /Year Started Month / Year Complete Reason for Leaving (Attach separate sheet to list additional employment information) Approved: January 2009 Doctors Hospital Allied Health Professional Application Page 3 of 13

LICENCES, CERTIFICATIONS, REGISTRATIONS Please list additional information on a separate sheet if space provided below is not sufficient Copy of Curricula Vita/Resume is NOT accepted as a substitute. OHIO LICENSE A copy of all current licenses MUST accompany this application Acquired License # Type Acquired License # Type OTHER STATE LICENSES Lists all past and current State License # Type State License # Type CERTIFICATIONS A copy of all current certifications (ex. Certificate to Prescribe) MUST accompany this application Certifying Agency License # Type Certifying Agency License # Type FEDERAL DEA NUMBER (if applicable) DEA Number Issued Approved: January 2009 Doctors Hospital Allied Health Professional Application Page 4 of 13

CPR CERTIF ICATIONS: Are you certified in CPR?? Yes (attach copy of certificate(s))? No Check Classifications(s)? Basic Life Support (BLS)? No? Advanced Cardiac Life Support? No? Health Care Provider (Core C)? No? Neonatal Resuscitation Program? No? Pediatric Advanced Life Support? No Other professional certification or credentials (please include description and copy of certification) Approved: January 2009 Doctors Hospital Allied Health Professional Application Page 5 of 13

PROFESSIONAL /MEDICAL SPECIALTY INFORMATION Board Certified Specialty Certificate Number Issued Expired Board Certified Specialty Certificate Number Issued Expired Board Certified Specialty Certificate Number Issued Expired *Note: Submit copies of all certificates with applicat ding copies of letters attesting to board eligibility. Please submit a copy of the Certificate of Insurance showing policy holder, coverage, limitations and expiration date. Provide professional liability insurance coverage information for past 5 years. MALPRACTICE CARRIER PROFESSIONAL LIABILITY INSURANCE COVERAGE Carrier Name Address/Street City/State/Zip Fax Website Have there been or are there currently pending any malpractice claims, suites, judgments, settlements or arbitration proceedings involving your professional practice? Yes No If you answered YES to the above, please provide the following information: *DATE SUIT OR CLAIM WAS INITIATED *CURRENT STATUS OF THE CASE *YOUR INVOLVEMENT WITH PATIENT(S) *YOUR ACCOUNT OF THE CASE *NAME OF PATIENT(S) *DATE OF DETERMINATION (IF REACHED) If you answer YES to any of the following questions, p s * Have you ever been denied professional liability coverage or had coverage canceled? Yes No * Has your liability insurer refused to renew your policy or placed limitations on the Scope of your coverage, or has any carrier expressed intent to deny, cancel, not Renew or limit your coverage? Yes No I attest that my Professional Liability Insurance covers the scope of my practice (i.e. to include all privileges being requested with this application) at Doctors Hospital. Signature Approved: January 2009 Doctors Hospital Allied Health Professional Application Page 6 of 13

DISCLOSURE OF INFORMATION Please answer the following questions yes or no. If your answer to questions 1 to 11 is yes or if your answer to question 12 is no, please provide a written explanation on a separate sheet. 1. Have you ever had any judgments taken against you arising out of a claim of malpractice? Yes No 2. Have you ever had any settlements made by you or on your behalf by any other person arising out of a malpractice claim made against you? Yes No 3. Are any claims now pending against you which arise out of alleged malpractice on your part? Yes No 4. Have you ever had any license, certificate or other legal credential in any state or other jurisdiction revoked, suspended, otherwise limited, or have you at any time voluntarily surrendered same? Yes No 5. Have you ever had your privileges at any hospital or other health care institution revoked, suspended, otherwise limited, or have you at any time voluntarily surrendered any such membership? Yes No 6. Have you ever had any personal, physical or mental health problems that may limit your ability to practice? Yes No 7. Have you ever been arrested for a defendant in a felony criminal matter? Yes No 8. Do you have history of engaging in the illegal use of drugs? Yes No ( Illegal use of drugs means the use of any controlled substance illegally obtained, i.e, not obtained pursuant to a valid prescription and not taken in accordance with the direction of a licensed health care practitioner.) 9. Are you currently engaged in the illegal use of drugs? Yes No ( Currently does not mean on the day or even the weeks preceding the completion of this application. Rather, it means recently enough so that the illegal use may have an impact on one s ability to practice.) 10. Are you currently in treatment for addiction to drugs or alcohol? Yes No 11. Have you ever been disciplined for a violation of ethical standards by any professional organization(s)? Yes No 12. Are you able to perform the procedures and the essential functions of the position for which you have applied, with or without reasonable accommodation g to accepted standards of professional performance and without posing a direct threat to patients? Yes No Approved: January 2009 Doctors Hospital Allied Health Professional Application Page 7 of 13

CONFIDENTIALITY STATEMENT OF UNDERSTANDING This statement summarizes the responsibilities and obligations of all persons who use, create or receive confidential information belonging to OhioHealth patients and to the OhioHealth member hospitals, as set out in the Hospital SPP Security & Confidentiality Policies & Procedures. It is the responsibility of all persons granted access to confidential information to protect the confidentiality of patient and hospital information and to make use of that information only to the extent authorized and necessary to provide patient care and/or to perform a proper Hospital or Educational function. I (name) recognize and acknowledge that all patient identifiable information and certain of the information the OhioHealth hospitals and Ambulatory Sites maintain for business purposes is confidential. By reason of my duties, I may come into possession of this confidential information even though I may not take any direct part in furnishing the patient services or developing the business information. I agree that I will not, at any time during or after my term of service as an Allied Health Professional, improperly disclose any confidential information to any person or permit any unauthorized person to examine or make copies of any reports, documents or on-line information that comes into my possession. Additionally, as this confidential information is available on a need-to-know basis, I will not access confidential information without authorization will do so only when required to do so. I recognize that the unauthorized disclosure of confidential information is totally prohibited. I also recognize that the disclosure of or sharing of passwords, access codes and key cards assigned to me is prohibited and that I am accountable to them for any improper access to information gained with these privileges. My access privileges are the equivalent of my legal signature and I shall take all reasonable and necessary steps to protect my access privileges. I acknowledge that I am responsible for all actions taken using those privileges. If I have reason to believe that the confidentiality of my access privileges has been broken, I shall immediately notify my supervisor, collaborating physician, or the Director of Information Services at my facility. I understand that if I violate any of the above statements, I may lose my access privileges immediately and that any violation may result in corrective action from my employer, sponsoring organization or academic institution in the interest of the patient and Hospital. If employed in a physician s private practice: I also acknowledge that violation against any of the above statements will reflect upon my employer and will result in corrective action by the Medical Executive Committee for my employer as well. Applicant Name (Print) Applicant Name (Signature) Approved: January 2009 Doctors Hospital Allied Health Professional Application Page 8 of 13

UNDERSTANDING OF DUTIES AS AN ALLIED HEALTH PROFESSIONAL That I am employed by (Collaborating Physician and/or Hospital Name) I have read the job description and/or written stateme statement. and responsibilities and concur with that That no one may substitute for me in performing these stated duties at Doctors Hospital. I understand that Allied Health Professionals are not considered members of the medical staff and do not have the rights and privileges of a member of the medical staff. The hospital permission for performing these duties in the hospital requires approval of the Chair of Allied Health Professional Committee, Chief Medical Office (CMO) or his/her designee. That such permission may be withdrawn without recourse to appeal mechanism. Applicant (Signature) ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ TO BE COMPLETED BY: Collaborating physician ( if privately employed) and/or Hospital Supervisor ( if employed by the hospital) I understand that as the employer of the above Allied Health Professional, I shall assume full responsibility and be fully accountable for the conduct of the individual within the hospital. Collaborating Physician (Print) Collaborating Physician (Signature) Approved: January 2009 Doctors Hospital Allied Health Professional Application Page 9 of 13

RELEASE OF INFORMATION / STATEMENT OF APPLICANT Please read carefully before signing All information submitted by me in this application is true to my best knowledge and belief. I fully understand that any misstatement in, or omissions from this application may constitute cause for denial of appointment, or cause for summary dismissal from the Allied Health Professional category. By applying for appointment to the Allied Health Professional category, I acknowledge that I have the responsibility to read the Allied Health Professional Manual. I agree to be bound by the terms of such documents and all other applicable policies as may from time-to-time be in effect if I am appointed. I agree to function in accordance with the ethical principles of my profession. By applying for appointment, I hereby signify my willingness to appear for interviews in regard to my application. I hereby authorize the medical staff representatives to consult with administrators and members of the medical staffs of other hospitals or institutions with which I have been associated and with other entities, including past and present malpractice carriers, who may have information bearing on my professional training, competence character and ethical qualifications. I hereby further consent to the inspection by the medical staff and their representatives of all documents that may be material to an evaluation of my professional qualifications and competence to carry out the clinical privileges requested as well as my moral and ethical qualification for the Allied Health Professional category. I hereby consent to and authorize the medical staff and its representatives to report, release and exchange information among themselves and to the Secretary of the Department of Health and Human Services and the Medical Board of the State of Ohio. I hereby further release from liability all representatives of the medical staff for their acts performed in good faith, without malice and in reasonable belief that any information gathered or exchanged is warranted by the facts known to them. I understand and agree that this consent is irrevocable and as long as the hospital may be under a duty to report information regarding the applicant pursuant to the Health Care Quality Improvement Act of 1986; Pub. L. 99-660. I understand and agree that I, as an applicant for the Allied Health Professional category or privileges, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics and other qualifications and for resolving any doubts about such qualifications. I also understand and agree that no such action will be taken on this appointment application until it is complete and all outstanding questions with respect to the application have been resolved. A photocopy of this waiver shall be as effective as the original when so presented. Applicant (Print) Applicant (Signature) Approved: January 2009 Doctors Hospital Allied Health Professional Application Page 10 of 13

AUTHORIZATION AND RELEASE TO CONDUCT BACKGROUND CHECKS NOTICE TO APPLICANTS An investigative report including fingerprinting and/or a criminal background check, information concerning your character, employment history, general reputation, personal characteristics, police record, education, qualifications and motor vehicle record will be obtained in connection with your application for me leges at an OhioHealth facility. Upon a written request made to Doctors Hospital, and within five (5) days of the request, the name, address and phone number of the reporting agency and the nature and scope of the report will be disclosed to you. Before any adverse action is taken, based in whole or in part on the information contained in the report, you will be provided a copy of the report, the name, address and telephone number of the reporting agency, a summary of your rights under the Fair Credit Reporting Act as well as additional information on your rights under the law. Applicant (Signature) CONSENT TO OBTAINING REPORTS Please read carefully before signing I have read the above Notice to Applicants and hereby authorize Doctors Hospital to obtain investigative reports as described. I understand that I have the right to make a written request within a reasonable amount of time to receive additional, detailed information about the nature and scope of any investigative report including the name, address, and telephone number of the reporting agency. I hereby authorize any present or former employers, educational institutions, criminal justice agencies, and departments of motor vehicles or public agency, to submit information or opinions about me including data received from other sources in order that my qualifications can be evaluated. I hold said persons and/or organizations blameless and without liability for statements or opinions made regarding my character, experience or qualifications. I hereby release and hold harmless Doctors Hospital, its predecessors, successors, assignees, trustees, directors, officers, administrators, employees and agents from any and all liability and responsibility, damages and claims of any kind whatsoever arising from this investigation of my background. By my signature below I acknowledge that I have read and understand all of the above statements Applicant (Print) Applicant (Signature) of Birth Social Security Number Maiden or other name(s) used Please provide the following information for the past seven (7) years. Use the back of this sheet if needed. 1. Present Street County / s lived at this address 2. Present Street County / s lived at this address 3. Present Street County / s lived at this address Approved: January 2009 Doctors Hospital Allied Health Professional Application Page 11 of 13

INFORMATION AGREEMENT I understand that Dublin Methodist Hospital, Riverside Methodist Hospital, Grant Medical Center, Doctors Hospital, Grady Memorial Hospital, and other OhioHealth entities are a part of a single health care system and that the information is shared between these facilities. As a condition of my appointment, I consent to the release of any and all information relative to my appointment and exercise of privileges between these facilities, including peer review that is maintained, received, and/or generated by either. I further understand that this information can and will be used as part of the respective facilities quality assessment and improvement activities and can form the basis for corrective action. Applicant (Print) Applicant (Signature) Approved: January 2009 Doctors Hospital Allied Health Professional Application Page 12 of 13

MEDICAL PROFESSIONAL REFERENCES References must be of the same specialty. -CANNOT accept collaborating physician- Name/Title: Address: : Fax: Email: ****************************************************** ***************** Name/Title: Address: : Fax: Email: ****************************************************** ***************** PEER PROFESSIONAL REFERENCE WHO HAS WORKED EXTENSIVELY WITH YOU (SAM E DEGREE) Name Address/Street City/State/Zip Fax Relationship Approved: January 2009 Doctors Hospital Allied Health Professional Application Page 13 of 13