Attachment 3 - Emergency Disaster Privilege Pre-Application Checklist - LIP.pdf

Attachment 3: Indian Health Service (IHS) Emergency/Disaster Privilege Pre‐Application Checklist (LIP)

Last Name ________________________ First Name ________________________ Middle Name __________________

Degree __________________ Other Name Used/Maiden Name ______________________ NPI # __________________

Primary Specialty ___________________________________ Sub‐Specialty ____________________________________

Identification Type: __________________________ ID # _____________________ Expiration Date ________________

Primary Office Address, City, State, Zip __________________________________________________________________

Primary Office Phone with Area Code ____________________________ Email _________________________________

Current Affiliation Address, City, State, Zip _______________________________________________________________

Affiliation Dates: From _______________ To _______________ Position _____________________________________

Please list all state where you have held a medical license, both active and inactive:

State – License # ‐ Expiration Date State – License # ‐ Expiration Date State – License # ‐ Expiration Date

State – License # ‐ Expiration Date State – License # ‐ Expiration Date State – License # ‐ Expiration Date

State – License # ‐ Expiration Date State – License # ‐ Expiration Date State – License # ‐ Expiration Date

DEA License # __________________ Exp ___________ State CDS License # (If Applicable) ______________ Exp _________

Specialty in which emergency/disaster privileges are desired:

Anesthesiology Radiology Pediatrics Family Medicine

Dentistry/Oral Surgery Ophthalmology Psychiatry Urgent Care

Internal Medicine Emergency Medicine Pathology OB/GYN

Surgery Podiatry Other (Please Enter):

Peer and Affiliation Reference: Name of current hospital or medical staff member(s) who possess personal knowledge regarding applicant’s ability to act as a licensed independent practitioner during a disaster:

Peer Name ___________________________________ Degree __________________ Specialty ____________________

Phone w/Area Code _____________________________ Email ______________________________________________

Current Affiliation _________________________________ Location __________________________________________

Phone w/Area Code _____________________________ Email ______________________________________________

Supervisor’s Name __________________________________ Contact Info _____________________________________

Indian Health Service (IHS) Emergency/Disaster Privilege Pre‐Application Checklist (LIP)

Professional Liability Insurance Carrier

Name of Carrier _____________________________________________________________________________________

Policy # _____________________________ Dates of Coverage ______________________________________________

Emergency Contact

Name _____________________________________________ Phone w/Area Code ______________________________

During this emergency I agree to provide professional services that are within the scope of my education, licensure, and expertise in a manner consistent with standards, policies and practices of my profession. I understand and acknowledge that any privileges applied for, and granted, will be for the duration of the present emergency and shall terminate automatically when the state of emergency ends. The privileges shall be terminated immediately if I have misrepresented or withheld any information required by this pre‐application checklist or subsequent information required by the individual facility. Privileges may be denied or terminated at any time at the discretion of the person who has direct oversight. Denial or termination of disaster privileges, regardless of the circumstances, shall not give rise to the right for a hearing, review or appeal under the respective medical staff bylaws or any other standard, regulation or law.

Date Print Applicant Name Applicant’s Signature

Required Documents: The following documents will need to be supplied for application, and may need to also be presented in person at the facility for verification.

Completed and Signed Pre‐Application Checklist

Signed Statement of Understanding and Release

Government Issues Photo Identification (Present at facility upon arrival)

Any Additional Documents/Information Requested By Specific Facility

Indian Health Service

Statement of Understanding and Release

I authorize the Indian Health Service (IHS) and its representatives to inquire of any individual or entity with whom or which I have been associated (including medical malpractice carriers) who or which it deems relevant in its assessment of my professional competence, character and ethical qualifications.

This includes any information otherwise protected from disclosure by the Privacy Act, 5 United States Code (U.S.C.) 552a, et seq. and/or the Health Insurance Portability and Accountability Act of 1996, Public Law 104‐191. This authorization includes copying and inspecting any documentation (including but not limited to any general medical records, behavioral health records and substance abuse treatment records), which the IHS and its representatives deem relevant.

I consent to the disclosure by the IHS and its representatives of any information regarding my professional services at any IHS facility to any individual or entity to whom or which I subsequently apply for clinical privileges, membership, or licensure. Additionally, I release the IHS from any liability for providing such information in response to any inquiry made by any IHS employee to another IHS employee.

I release from any sort of liability the United States, the IHS, any of their representatives, and any third parties from whom or which is obtained either information or documentation for the above purposes.

I understand that I have the right to review information received about me from any outside primary source except references or recommendations that are peer review protected. In the event that the information obtained from outside primary sources varies substantially from the information I have provided, I am aware that I have the right to review and correct, if necessary, the information obtained.

Upon request, I agree to appear for purposes of responding to questions relating to any record, document or information obtained pursuant to the foregoing paragraph. I understand that my refusal to so appear may constitute cause for future denial of clinical privileges and/or appointment to any medical staff or other healthcare position for the

IHS.

All information submitted by me in this application is true and correct to the best of my knowledge. I understand that any intentional misstatement in or omission from this application may constitute cause for denial of appointment or summary dismissal from the clinical staff, at the sole discretion of the deciding entity. I agree that in either of these events, I waive all rights of recourse and damages against the United States, the IHS, and its representatives.

Applicant’s Signature Date