DOCUMENTS CHECKLIST CRNA

DOCUMENTS CHECKLIST CRNA Please include clear copies of the following documents with completed application: o Application Form Initialed, signed and dated o Release and Authorization Form Signed and dated o Skills Checklist Signed and dated o Three Peer References Completed by CRNA/MD o Copy of Curriculum Vitae Must include a complete chronological list of activities since graduation detailed by Month and Year o Gaps larger than 30 days in chronology must be accounted for o If you are a locum tenens provider, your CV must reflect ALL Locum Assignments o Copy of Current Malpractice Binder Or list of carries from the past 5 years o Additional Documentation - As requested pertaining to any questions answered in the affirmative under Professional Liability and Disciplinary Action. o Copies of ALL State Licenses o Copy of Nursing and Anesthesia diplomas o Copy of AANA/CRNA/CCNA Certification Cards o Copy of NPI Letter o Medicare/Medicaid/Blue Cross Numbers o Copy of Current CME s From the past 24 months o Copy of Current BLS, ACLS, PALS All that are applicable o Copy of Immunization Records PPD/TB or Chest X-Ray, Rubella, Rubeola, Measles, Mumps, Hepatitis B, Varicella o Drivers License Clear, color copy o Recent Photo Passport size preferred; jpg format if possible Rhino Medical Services 2000 East Lamar Boulevard # 250 Arlington, TX 76006 Phone: (866) 267-4466 Fax: (800) 850-2005 consultants@rhinomedical.com www.rhinomedical.com

Skills Checklist: General Anesthesia & Analgesia Preoperative evaluation Inhalation agents Sevoflurane Desflurane Isoflurane Intramuscular agents Regional Anesthesia Topical Infiltration Interthecals Spinal Hypobaric Hyperbaric Bier blocks Field blocks Other peripheral blocks Transtracheal blocks Epidurals Axillary blocks Eye blocks Intracapsular Retrobulbar Peribulbar Interscalene blocks Intercostal Intravenous administration of: Crystalloids Blood Blood by-products Colloids Procedures Peripheral IV placement Central line placement Internal jugular Subclavian Central line monitoring External jugular line placement Arterial line placement Arterial line monitoring Swan ganz catheterization and monitoring Cardiac output monitoring Mechanical ventilation Resuscitation techniques and therapy Defibrillation External cardiac pacing Emergency Management (airway/dysrhythmia/vital signs) in OR and PACU Cardiopulmonary bypass techniques Autotransfusion techniques Hypotensive techniques Hypothermia techniques Fiberoptic intubation Endotracheal intubation LMA placement ICP monitoring Special Categories Diagnostic and therapeutic blocks Steroid blocks Spinals-differential Sympathetic blocks (Continued on next page) Initials

Skills Checklist: Drugs Alpha blockers Beta blockers Anticoagulants Anticoagulant antagonists Barbiturates Cardiac drugs Antiemetics Diuretics Dissociative agents Hypnotics Muscle relaxants Muscle relaxant reversal agents Narcotic antagonists Parasympathomimetics Parasympatholytics Steroids Sympathomimetics Tranquilizers Non-narcotic analgesics Vasoactive Specialties or Specific Skills Neuro Cardiac Thoracic Transplants Urology GYN ENT Eyes OB Major Vascular Burns Pediatrics Neonates Geriatrics Comments Provider Printed Name Provider Signature CONSENT OF MEDICAL STAFF APPLICANTS I hereby affirm that the information provided by me on this application and attachments is true, complete and correct, and that Rhino Medical Services will rely on the truthfulness of my statements in evaluating my potential as a Rhino Medical Services Provider. I hereby release from liability Rhino Medical Services, its staff and representatives for their acts performed in good faith and without malice in connection with evaluation of my application, credentials and qualifications. I further release from liability physicians, hospital and other references for the good faith release of information regarding my professional capabilities and performances, and agree that other sources not listed by me may be contacted. I further acknowledge that (a) the decision to offer me contractual work with Rhino Medical Services is solely at the discretion of Rhino Medical Services, (b) any information received from references by Rhino Medical Services may not be released to me without the consent of the reference, and (c) I agree that I will not enter into an arrangement to provide temporary or permanent CRNA services with any individual, group or institution to whom I am referred by Rhino Medical Services, except through Rhino Medical Services, or with written Rhino Medical Services consent. Provider Signature

Application for Appointment to Medical Staff IDENTIFYING INFORMATION (FOR INTERNAL PURPOSES ONLY) LAST NAME FIRST NAME MIDDLE NAME MAIDEN NAME SOCIAL SECURITY NUMBER HOME ADDRESS CITY STATE ZIP CODE HOME TELEPHONE COUNTY EMAIL ADDRESS MOBILE TELEPHONE BIRTHPLACE MARITAL STATUS MALE FEMALE DATE OF BIRTH CITIZENSHIP NPI NUMBER NAME OF SPOUSE EMERGENCY CONTACT PHONE NUMBER M S W D DESIRED WORK SITUATION Available Preferred Assignment Length Maximum Travel Distance Full Time Part Time Over Time Call Weekends FACILITY PREFERENCES Small Hospital Medium Hospital University Hospital Trauma Office Surgery Center Supervised Solo Either UNDERGRADUATE TRAINING COLLEGE OR UNIVERSITY DEGREE HONORS CITY STATE DATES (MONTH/YEAR) COLLEGE OR UNIVERSITY DEGREE HONORS CITY STATE DATES (MONTH/YEAR) GRADUATE TRAINING COLLEGE/UNIVERSITY/FACILITY DEGREE HONORS CITY STATE DATES (MONTH/YEAR) NATIONAL CERTIFICATION ARE YOU CURRENTLY CERTIFIED? DATE OF ORIGINAL CERTIFICATION NAME OF CERTIFICATION ONLY ANSWER IF NOT CURRENTLY CERTIFIED Have you ever taken the national examination and failed to pass? If yes, how many times? Have you applied for the certification exam? If yes, when are you scheduled to take the exam? EXAMINATIONS/REGISTRATION LICENSES SBTPE NCLEX State Constructed Number of times taken? Last Taken? PROFESSIONAL REFERENCES (please complete in full) Either CRNA/MD 1. Name Phone Email 2. Name Phone Email 3. Name Phone Email

Health Status Questionnaire Preliminary consideration of professional staff appointment/reappointment has been extended to you. The position and clinical privileges you have requested require you to demonstrate that your physical and mental condition is adequate to perform the duties of the position and/or to exercise the prerogatives of professional staff membership. As a first step to demonstrating this capacity, please provide responses to the following questions. Any YES answer will not automatically disqualify you from locum tenens and/or professional staff appointment. 1. Do you have any physical or mental disabilities which would interfere with your professional duties or in any way impose a risk to patients, members, or yourself? If yes, please state or describe any reasonable accommodations that can be made to enable you to safely and efficiently perform the duties and avoid risk to others. 2. Are you currently using any controlled substances? If yes, please describe. 3. Are you now or have you ever been treated or received institutional care for any chronic / recurring illnesses, alcoholism, or other chemical dependency? If yes, please describe and accompany with a letter from the treating physician/institution stating dates, results, and current status. 4. Have you had a positive Rubella Titer? If yes, what date? 5. Have you had a positive Rubeola Titer? If yes, what date? 6. Have you ever received Rubeola Vaccine? If yes, what date? 7. Have you had a Varicella Titer? If yes, what date? 8. Have you had a Purified Protein Derivative Test within the last year? If yes, what was the result? If the test was positive, please attach results of a base line chest x-ray less than 5 years old. 9. Have you had a Hepatitis B antigen antibody test? If yes, what date, and what were the results? If the results were negative, or you have not had such a test, please consult infection control to discuss obtaining Hepatitis screening and/or immunization consultation. Comments: Provider Signature

FITNESS FOR POSITION If you answer yes to question #3 or #4, provide a full explanation on a separate sheet 1. The essential function of a healthcare provider is to offer a standard of care that is acceptable within his/her specialty. Are you capable of performing this function with or without reasonable accommodations? 2. Are you authorized to work as an independent contractor in the United States? 3. Are you currently abusing alcohol, using any illegal drugs, or failing to take legally prescribed drugs in the manner prescribed? 4. Have you abused alcohol, used illegal drugs, or failed to take legally prescribed drugs in the manner prescribed in the past? If yes, which drugs, and how recently? PROFESSIONAL LIABILITY If you answer yes to any of the following, provide full explanation on a separate sheet 1. Have any malpractice claims, suits, settlements or arbitration proceedings been made against you? 2. Are there any claims, suits, or settlements pending against you or any professional entity in which you are a member? If you answered YES to any of these questions, please include a personal summary on each case to include: year occurred, status closed, etc.), settlement amount, detail of the case, malpractice carrier. (i.e., pending, In addition to your summary of events, please include any and all additional documentation available from attorneys, and/or malpractice carriers. DISCIPLINARY ACTIONS Any YES answer will not automatically disqualify you from consideration for placement on Rhino Medical Services roster of eligible providers. 1. Have you ever been convicted of a felony or a misdemeanor? 2. Have you ever been convicted of any violation of a state or federal law relating to controlled substances? 3. Have you ever been denied or surrendered a state or federal controlled substances certificate? 4. Has your license to practice medicine in any state been reprimanded, sanctioned, placed on probation, curtailed, suspended, revoked, restricted, denied or voluntarily surrendered? 5. Have you ever been denied a certificate by, or the privilege of taking an examination before, any state medical board? 6. Have your staff/clinical privileges at any hospital, healthcare facility, or clinic been denied, revoked, suspended, curtailed, limited, or placed under conditions restricting your practice? 7. Have you ever been terminated from employment? 8. Have you ever been disciplined by any state board for any violation of the Medical Practice Act or unethical conduct? 9. Have you ever been denied provider participation in any state or federal Medicare of Medicaid programs? 10. Have you ever been terminated, sanctioned, penalized or had to repay money to any state or federal Medicare/Medicaid programs? 11. Have you ever been the subject of any investigative or disciplinary proceedings or reprimanded by a governmental or administrative agency? 12. Have you ever been convicted of a violation of any federal or state narcotic laws? 13. Have you ever been disciplined by a hospital staff, internship or residency program? 14. Is there any other issue, which should be disclosed that may have an adverse impact on your ability to deliver effective healthcare? Military Service: On a separate sheet of paper please explain the circumstances of any less than honorable discharge received. A less than honorable discharge will not be an automatic bar to placement on Rhino Medical Services roster of eligible Providers. MILITARY SERVICE Are you Vet-Pro Approved? Have you served in the military? Branch s of Service

Release and Authorization (Please read carefully) By my signature below, I authorize Rhino Medical Services to conduct background and reference checks on me regarding any information related to possible placement as a healthcare provider. This includes information on my education, licensing, work history, Medicare/Medicaid sanctions, malpractice claims and insurance eligibility, and criminal history. Rhino Medical Services may gather the information from various sources including, but not limited to, consumer reporting agencies, hospitals, medical institutions or organizations, personal references, physicians, employers (past and present), business and professional associates (past and present), governmental agencies and instrumentalities (local, state, federal, or foreign), university transcript offices, medical schools, and the Office of the Inspector General. I authorize Rhino Medical Services to confirm information contained on any document that I provide Rhino Medical Services, including my curriculum vitae. I consent to Rhino Medical Services sharing this information with Rhino Medical Services clients and affiliates. I understand that upon my request, Rhino Medical Services will disclose the nature and scope of information contained in my file in accordance with federal law. A request for disclosure of information in my file must be made in writing and directed to my recruiting consultant. I authorize the above-named entities and individuals to release to state licensing boards, hospitals, and Rhino Medical Services, any information (written or oral), including medical information, files or records about me in their possession required for evaluation of my qualifications for placement as a locum tenens provider. I hereby release the above-named individuals and entities, including Rhino Medical Services, from all liability for the release of information to any state licensing board, hospital, or its agents. I further authorize Rhino Medical Services, its agents, and affiliates to release this information, including medical information, to federal, state, county, or local government entities, hospitals or other healthcare facilities, insurance providers, or any other person upon showing that the release of information is vital to the general public s health, safety and welfare. I make this release for the purpose of allowing Rhino Medical Services to assist in my request for a license to practice in my specialty and/or to assist in my efforts to work as a healthcare provider for Rhino Medical Services clients. Printed Name Signature

Authorization Agreement for Direct Deposit Use this form to add, change or cancel a direct deposit. All changes must be in writing and accounts must be canceled through payroll to be valid. To set up direct deposit, please take the following actions: Attach a voided check from the account. (Deposit slips are not accepted) Have the account currently set up at your bank. Verify that your bank accepts direct deposits. Verify your bank s routing number and your account number. tify the bank that you are setting up direct deposit. Verify if they have any special requirements. Account Information: New Direct Deposit Change Direct Deposit Cancel Direct Deposit Bank Name: Bank Routing # Bank Account # Authorization given by: Name (printed) Signature

Form W-9 Request for Taxpayer (Rev. January 2003) Identification Number and Certification Department of the Treasury Internal Revenue Service Print or type See Specific Instructions on page 2. Name Business name, if different from above Check appropriate box: Address (number, street, and apt. or suite no.) City, state, and ZIP code List account number(s) here (optional) Give form to the requester. Do not send to the IRS. Individual/ Exempt from backup Sole proprietor Corporation Partnership Other withholding Requester s name and address (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note: If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Part II Certification Social security number or Employer identification number Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. person (including a U.S. resident alien). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN. (See the instructions on page 4.) Sign Here Signature of U.S. person Purpose of Form A person who is required to file an information return with the IRS, must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. U.S. person. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. Note: If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester s form if it is substantially similar to this Form W-9. Foreign person. If you are a foreign person, use the appropriate Form W-8 (see Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a saving clause. Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the recipient has otherwise become a U.S. resident alien for tax purposes. If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement that specifies the following five items: 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. 4. The type and amount of income that qualifies for the exemption from tax. 5. Sufficient facts to justify the exemption from tax under the terms of the treaty article. Cat. No. 10231X Form W-9 (Rev. 1-2003)