Dental Services Credentialing Process and Application - Attachment B.xml

The following items are needed to perform the credentialing process: Application Kaper 3 Med Staff Evaluations, including typed letters of reference from those filling out the evaluations Copy of Driver’s License Copy of Social Security Card Copy of Medical License /APRN License Copy of board certificates Copy of med school /APRN certificates Copy of liability insurance Signed and dated CV Copy of CME’s Copy of DEA Copy of any other medical certificates ( ie : CPR cards, any other certificates not mentioned above) WESTERN STATE HOSPITAL Hopkinsville , Kentucky APPLICATION FOR MEDICAL STAFF MEMBERSHIP AND REQUEST FOR CLINICAL PRIVILEGES PODIATRIST: DATE: BOARD CERTIFIED IN: DATE: I am requesting the following privileges, for which I am qualified by education, experience and training. Please check the procedures in which you are proficient. Proficiency may mean actual performance of the procedure or supervision of the house staff. If your duties do not include the possibility of doing a specific procedure, please do not check it even if you have been certified to do so. COMPETENCY CLASS APPLIED FOR I PODIATRY _____Evaluate and Treat nail infections _____Corns _____Calluses _____Ingrown toenails _____Clipping and Debridement of toenails Please complete (items a-g) by checking Yes or No PLEASE READ CAREFULLY a. Have you had previously successful or currently ( ) Yes* ( ) No pending challenges to any licensure or registration (State or district, Drug Enforcement Administration) of the voluntary relinquishment of such licensure or registration? b. Have you had voluntary or involuntary termination of ( ) Yes* ( ) No medical staff membership or voluntary or involuntary limitation, reduction, or loss of clinical privileges? c. Have you had involvement in a professional liability ( ) Yes* ( ) No action under circumstances specified in the medical staff bylaws, rules and regulations, and policies? d. Have you been involved in judicial proceedings in ( ) Yes* ( ) No which professional malpractice was alleged? e. Are you physically and mentally capable of providing ( ) Yes ( ) No* the services required by the privileges requested? f. Have you participated in continuing education necessary ( ) Yes ( ) No* to maintain proficiency in performing the required privileges. g. Are you presently under investigation or have you ( ) Yes* ( ) No ever been sanctioned by a federal or state program such as Medicare or Medicaid, disbarred or otherwise been found culpable of misconduct under the law involving the health care system? *PLEASE PROVIDE AN EXPLANATION AND ATTACH TO PRIVILEGE REQUEST FORM. I am enclosing copies of any documents, which verify training and education in these areas (continuing education courses, transcripts, and verification of training, vitae, certification, licensure, supervisory letters, and performance evaluations). I have read and am familiar with and agree to abide by the current Medical Staff Bylaws, the Bylaws of the Governing Body and the Medical Staff Rules and regulations in the Hospital Manual. I will abide by the Code of Ethics of my professional association. I consent to the inspection of my personnel file, medical file, and all hospital records in order that an evaluation of my professional, physical, and ethical qualifications and performance may be done. I understand the following areas will be reviewed in the reappointment process: clinical performance, participation in appointed hospital committees, patient care audit and utilization review findings, medical record deficiencies, current professional certification, health status, professional ethics and conduct as other areas which may be pertinent to the granting of privileges. I release from civil liability those reviewing or providing information relative to credentials, staff membership and privileges. Print Name Signature of Applicant Date: CRITERIA FOR GRANTING CLINICAL PRIVILEGES 1. EDUCATION/TRAINING: Meets requirements for Class I as described below: Class I – Completion of a one-year general podiatry residency 2. CURRENT PROFESSIONAL COMPETENCY AS EVIDENCED BY, BUT NOT LIMITED TO: New Appointees: Based on review of previous employer assessments. Renewals: Observation of clinical performance, results of quality care monitors and annual proficiency report, if applicable. 3. HEALTH STATUS AS EVIDENCED BY, BUT NOT LIMITED TO: New Appointees: Based on review of physical examinations and previous employer assessments. Renewals: Physical and mental ability to carry out staff responsibilities as determined through personal observations and quality care monitoring. I KAPER-1 (04/2009) Part B, Section 1 For Health Care Providers Desiring Initial Hospital or Health Care Facility Privileges NOTE: Submission and approval of a pre-application for privileges may be required by a health care facility prior to the facility’s processing a completed KAPER-1 (04/2009), Part B, Section 1. Therefore, a provider desiring initial health care facility privileges is advised to contact the facility for information relating to any pre-application requirements. Commonwealth of Kentucky Instructions - Form (04/2009), Part B, Section 1 A. Uniform Application for Evaluation (Credentialing) Form. Following is the form KAPER-1 (04/2009), Part B, Section 1, developed pursuant to KRS 304.17A-535(5) for evaluation (credentialing) of a health care provider. The form is available on the Web site of the Kentucky Department of Insurance at http://insurance.ky.gov . Prior to completing this form, a health care provider who desires initial evaluation (credentialing) by a hospital or health care facility is advised to contact that specific hospital or health care facility for information regarding submission of the complete KAPER-1 (04/2009), Part B, Section 1, and required attachments, as applicable and specified in item C of this instruction. B. Cover Letter. A cover letter, which is signed and dated by the health care provider who desires evaluation (credentialing) by a hospital or health care facility, requesting consideration of the complete KAPER-1 (04/2009), Part B, Section 1, and required attachments, as applicable and specified in item C of this instruction, may be required. C. Required Attachments. For a Physician, unless otherwise specified in this instruction, one (1) photocopy of each of the following supporting documents should be labeled and attached to the complete form KAPER-1 (04/2009), Part B, Section 1, in the following order: 1. Current medical, dental or professional license or evidence of licensure, as applicable (If medical, dental or other health care provider, including a psychologist, has applied for, but not received this license, a copy of the application for this license will be accepted until a copy of the license is available for submission.); 2. Current federal drug enforcement agency (DEA) certificate for each state of practice. (If medical, dental or other health care provider, including a psychologist, has applied for, but not received this number, a copy of the application for a DEA number will be accepted until the DEA number is available for submission.); 3. Current state substance registration certificate, if applicable. (If medical, dental or other health care provider, including a psychologist, has applied for but not received this certificate, a copy of the application for this certificate will be accepted until a copy of the state substance registration certificate is available for submission.); 4. Proof of current professional liability insurance, including name, inception and expiration dates and amount of coverage (If medical, dental or other health care provider, including a psychologist, has applied for but not received professional liability insurance, a photocopy of the application for professional liability insurance will be accepted until the proof of current professional liability insurance is available for submission.); 5. Board certification/eligibility verification information; 6. Curriculum vitae (All time periods from receipt of degree to present must be accounted for); 7. Current photograph; 8. Photo identification (ID). Additionally, photo ID should be presented in person at the hospital or health care organization where participation is desired; and 9. Separate pages or supplemental forms, if any, in page number order. For an Allied Health Professional , unless otherwise specified in this instruction, one (1) photocopy of each of the following supporting documents should be labeled and attached to the complete form KAPER-1 (04/2009), Part B, Section 1, in the following order: 1. Current professional license or evidence of licensure (If multiple professional licenses are held by the allied health professional, a copy of each license and/or registration should be attached; for example, registered nurse (RN); 2. Current federal drug enforcement agency (DEA) certificate, if applicable for allied health professional specialty (If allied health professional has applied for but not been issued a DEA number, a copy of the application requesting this number may be submitted until a copy of the actual DEA number is available for submission.); 3. Current state substance registration certificate, if applicable (If allied health professional has applied for but not been issued a state substance registration certificate, a copy of the application requesting this certificate may be submitted until a copy of the actual certificate is available for submission.); 4. Statement of sponsoring health care provider (e.g., physician) or collaborative practice agreement, if applicable; 5. Proof of current professional liability insurance, including allied health professional name, inception and expiration date, and amount of coverage (If allied health professional has applied for but not been issued professional liability insurance, a copy of the application requesting coverage may be submitted until a copy of the approval of coverage is available for submission.); 6. Curriculum vitae or resume (All time periods from receipt of degree to present must be accounted for); 7. Current photograph; 8. Photo identification (ID). Additionally, photo ID should be presented in person at the hospital or health care organization where participation is desired; and 9. Separate pages or supplemental forms, if any, in page number order. I. PERSONAL IDENTIFICATION DATA 0 31750 0 0 Name: ___________________________________________________________________________________________ Last Suffix First Middle Maiden Name Degree FORMCHECKBOX Medical Staff FORMCHECKBOX Allied Health (please specify) ________________________________________________________________ Residence: __________________________________________________________ Phone: _______________________________________ __________________________________________________________ Fax: _______________________________________ __________________________________________________________ Primary Office Address: __________________________________________________ Phone: _______________________________________ __________________________________________________ Fax: _______________________________________ __________________________________________________ Secondary Office Address: __________________________________________________ Phone: _______________________________________ __________________________________________________ Fax: _______________________________________ __________________________________________________ Billing Office Address: __________________________________________________ Phone: _______________________________________ __________________________________________________ Fax: _______________________________________ __________________________________________________ Credentialing Address: 2400 Russellville Road ________________________________ Phone: 270-889-6025 ext. 226 ____________________ P.O. 2200 ___________________________________________ Fax: 270-886-4786__ __________________________ Hopkinsville, KY 42240_________________________________ Credentialing Contact: Amanda Knight ______________________________________ Credentialing Email: amandaj.knight@ky.gov ________ Preferred Mailing Address: FORMCHECKBOX Primary Office FORMCHECKBOX Residence FORMCHECKBOX Other (please specify) _______________________________________________ Phys. Email Address: _________________________ Prac . Admin's Email: _____________________ Office Web Address: ______________________ Date of Birth: ________________________ Gender: _________ Place of Birth: ____________________________________________________ Social Security #: ______________________________________ Marital Status: _____________________________________________________ Citizenship: ___________________________________________ Spouse: _________________________________________________________ (If not a US citizen, please complete the next three fields) Visa Status : ______________________________ Alien Reg. #: ________________________ Exp . Date: ________________________________ Language Spoken: ___________________________________________________________________________________________________________ ECFMG #: - - - Pager #: ______________________ FORMCHECKBOX Alpha FORMCHECKBOX Digital FORMCHECKBOX Voice (if applicable): Medicare #: ________________________________________________ Cellular #: ________________________________________________ Medicaid #: ________________________________________________ Answering service #: _______________________________________ UPIN: ____________________________________________________ Are you taking new patients? _________________________________ EIN: _____________________________________________________ Taxonomy Code: __________________________________________ NPI #: ____________________________________________________ Clinical Specialty/Subspecialty: _________________________________________________________________________________________________ Other interests in practice, research, etc.: _________________________________________________________________________________________ Name others with whom you are or will be associated in practice: ______________________________________________________________________ Nature of association: FORMCHECKBOX Solo FORMCHECKBOX Group FORMCHECKBOX Partnership FORMCHECKBOX Corporation Effective Date: ____________________________ Other: (please specify) ________________________________________________________________________________________________________ Name of Practice (if applicable): _________________________________________________________________________________________________ Covering physician(s) to be called in my absence (Allied Health Professionals list sponsoring physician): Name: ________________________________ Specialty: ____________________________ Telephone: _______________________________ Name: ________________________________ Specialty: ____________________________ Telephone: _______________________________ Name: ________________________________ Specialty: ____________________________ Telephone: _______________________________ II. EDUCATIONAL DATA (All periods of time must be accounted for from entrance into medical school to the present) Please indicate if your name at any educational institution is different than the name listed on your application. FORMCHECKBOX Yes FORMCHECKBOX No If YES, please identify other name(s): ___________________________________________________________________________________________ A. Schools Undergraduate College/University: _______________________________________________________________________________________________ Address: ___________________________________________________________________________________________________________________ City/State/ZIP: _______________________________________________________________________________________________________________ City St ZIP ZIP + Country Phone: _________________________ Fax: _________________________ Email (if available): __________________________________________ Degree: ________________________________________________________________________________________ _____________ / ____________ From (mm/ yy ) To (mm/ yy ) Medical/Dental/Other College: ___________________________________________________________________________________________________ Address: ___________________________________________________________________________________________________________________ City/State/ZIP: _______________________________________________________________________________________________________________ City St ZIP ZIP + Country Phone: _________________________ Fax: _________________________ Email (if available): __________________________________________ Degree: ________________________________________________________________________________________ _____________ / ____________ From (mm/ yy ) To (mm/ yy ) B. Internships Name: _______________________________________________________ _________________________________ _____________ / _____________ Type of Internship From (mm/ yy ) To (mm/ yy ) Address: ___________________________________________________________________________________________________________________ City/State/ZIP: _______________________________________________________________________________________________________________ City St ZIP ZIP + Country Phone: _________________________ Fax: _________________________ Email (if available): __________________________________________ During this internship, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? If YES, please explain on a separate sheet and attach. FORMCHECKBOX Yes FORMCHECKBOX No Name: _______________________________________________________ _________________________________ _____________ / _____________ Type of Internship From (mm/ yy ) To (mm/ yy ) Address: ___________________________________________________________________________________________________________________ City/State/ZIP: _______________________________________________________________________________________________________________ City St ZIP ZIP + Country Phone: _________________________ Fax: _________________________ Email (if available): __________________________________________ During this internship, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? If YES, please explain on a separate sheet and attach. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Check if more than two internships were begun or completed. Please supply the same information on a separate sheet and attach. C. Residencies Name: _______________________________________________________ _________________________________ _____________ / _____________ Type of Residency From (mm/ yy ) To (mm/ yy ) Address: ___________________________________________________________________________________________________________________ City/State/ZIP: _______________________________________________________________________________________________________________ City St ZIP ZIP + Country Phone: _________________________ Fax: _________________________ Email (if available): __________________________________________ Chairman/Chief of Service: _____________________________________________________________________________________________________ Did you complete the residency? FORMCHECKBOX Yes FORMCHECKBOX No During this residency, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? If YES, please explain on a separate sheet and attach. FORMCHECKBOX Yes FORMCHECKBOX No Name: _______________________________________________________ _________________________________ _____________ / _____________ Type of Residency From (mm/ yy ) To (mm/ yy ) Address: ___________________________________________________________________________________________________________________ City/State/ZIP: _______________________________________________________________________________________________________________ City St ZIP ZIP + Country Phone: _________________________ Fax: _________________________ Email (if available): __________________________________________ Chairman/Chief of Service: _____________________________________________________________________________________________________ Did you complete the residency? FORMCHECKBOX Yes FORMCHECKBOX No During this residency, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? If YES, please explain on a separate sheet and attach. FORMCHECKBOX Yes FORMCHECKBOX No Name: _______________________________________________________ _________________________________ _____________ / _____________ Type of Residency From (mm/ yy ) To (mm/ yy ) Address: ___________________________________________________________________________________________________________________ City/State/ZIP: _______________________________________________________________________________________________________________ City St ZIP ZIP + Country Phone: _________________________ Fax: _________________________ Email (if available): __________________________________________ Chairman/Chief of Service: _____________________________________________________________________________________________________ Did you complete the residency? FORMCHECKBOX Yes FORMCHECKBOX No During this residency, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? If YES, please explain on a separate sheet and attach. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Check if more than three residencies were begun or completed. Please supply the same information on a separate sheet and attach. D. Fellowship and/or Other Postgraduate Training Name: _______________________________________________________ _________________________________ _____________ / _____________ Type of Fellowship From (mm/ yy ) To (mm/ yy ) Address: ___________________________________________________________________________________________________________________ City/State/ZIP: _______________________________________________________________________________________________________________ City St ZIP ZIP + Country Phone: _________________________ Fax: _________________________ Email (if available): __________________________________________ Did you complete the fellowship? FORMCHECKBOX Yes FORMCHECKBOX No During this fellowship, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? If YES, please explain on a separate sheet and attach. FORMCHECKBOX Yes FORMCHECKBOX No Name: _______________________________________________________ _________________________________ _____________ / _____________ Type of Fellowship From (mm/ yy ) To (mm/ yy ) Address: ___________________________________________________________________________________________________________________ City/State/ZIP: _______________________________________________________________________________________________________________ City St ZIP ZIP + Country Phone: _________________________ Fax: _________________________ Email (if available): __________________________________________ Did you complete the fellowship? FORMCHECKBOX Yes FORMCHECKBOX No During this fellowship, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? If YES, please explain on a separate sheet and attach. FORMCHECKBOX Yes FORMCHECKBOX No Name: _______________________________________________________ _________________________________ _____________ / _____________ Type of Fellowship From (mm/ yy ) To (mm/ yy ) Address: ___________________________________________________________________________________________________________________ City/State/ZIP: _______________________________________________________________________________________________________________ City St ZIP ZIP + Country Phone: _________________________ Fax: _________________________ Email (if available): __________________________________________ Did you complete the fellowship? FORMCHECKBOX Yes FORMCHECKBOX No During this fellowship, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? If YES, please explain on a separate sheet and attach. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Check if more than three fellowships were begun or completed. Please supply the same information on a separate sheet and attach. E. Other Professional Training School: _______________________________________________________ ______________________________ _____________ / _____________ Chairman/Chief of Service From (mm/ yy ) To (mm/ yy ) Address: ___________________________________________________________________________________________________________________ City/State/ZIP: _______________________________________________________________________________________________________________ City St ZIP ZIP + Country Phone: _________________________ Fax: _________________________ Email (if available): __________________________________________ Degree: ____________________________________________________________________________________________________________________ School: _______________________________________________________ ______________________________ _____________ / _____________ Chairman/Chief of Service From (mm/ yy ) To (mm/ yy ) Address: ___________________________________________________________________________________________________________________ City/State/ZIP: _______________________________________________________________________________________________________________ City St ZIP ZIP + Country Phone: _________________________ Fax: _________________________ Email (if available): __________________________________________ Degree: ____________________________________________________________________________________________________________________ FORMCHECKBOX Check if more than two training programs were begun or completed. Please supply the same information on a separate sheet and attach. III. TEACHING APPOINTMENTS Name: _________________________________________________ __________________________________ ________________________________ Department Chief Type of Appointment Address: ___________________________________________________________________________________________________________________ City/State/ZIP: _______________________________________________________________________________ _____________ / _____________ City St ZIP ZIP + From (mm/ yy ) To (mm/ yy ) Phone: _________________________ Fax: _________________________ Email (if available): __________________________________________ Name: _________________________________________________ __________________________________ ________________________________ Department Chief Type of Appointment Address: ___________________________________________________________________________________________________________________ City/State/ZIP: _______________________________________________________________________________ _____________ / _____________ City St ZIP ZIP + From (mm/ yy ) To (mm/ yy ) Phone: _________________________ Fax: _________________________ Email (if available): __________________________________________ IV. Post-Graduate and Continuing Education Courses Have you participated in post-graduate/continuing education courses in the last three years? If YES, please supply an attached list and/or certificate of attendance. FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX List and/or certificates attached Do you have a cardio-pulmonary resuscitation certificate? FORMCHECKBOX CPR FORMCHECKBOX Yes FORMCHECKBOX No Date of Expiration ______________________ FORMCHECKBOX ACLS FORMCHECKBOX Yes FORMCHECKBOX No Date of Expiration ______________________ FORMCHECKBOX ATLS FORMCHECKBOX Yes FORMCHECKBOX No Date of Expiration ______________________ FORMCHECKBOX PALS FORMCHECKBOX Yes FORMCHECKBOX No Date of Expiration ______________________ FORMCHECKBOX NRP FORMCHECKBOX Yes FORMCHECKBOX No Date of Expiration ______________________ Please attach copies of all certificates. V. licensure information List all current and past professional health care licenses held and attach copies of all active licenses. Allied Health Professionals: list all certifications. State: License #: Date Issued: Expiration Date: Status: License Obtained by: KY State: _______ _____________ _____________ _____________ FORMCHECKBOX Active FORMCHECKBOX Inactive FORMCHECKBOX Exam FORMCHECKBOX Reciprocity State #2: _______ _____________ _____________ _____________ FORMCHECKBOX Active FORMCHECKBOX Inactive FORMCHECKBOX Exam FORMCHECKBOX Reciprocity State #3: _______ _____________ _____________ _____________ FORMCHECKBOX Active FORMCHECKBOX Inactive FORMCHECKBOX Exam FORMCHECKBOX Reciprocity State #4: _______ _____________ _____________ _____________ FORMCHECKBOX Active FORMCHECKBOX Inactive FORMCHECKBOX Exam FORMCHECKBOX Reciprocity State #5: _______ _____________ _____________ _____________ FORMCHECKBOX Active FORMCHECKBOX Inactive FORMCHECKBOX Exam FORMCHECKBOX Reciprocity State #6: _______ _____________ _____________ _____________ FORMCHECKBOX Active FORMCHECKBOX Inactive FORMCHECKBOX Exam FORMCHECKBOX Reciprocity State #7: _______ _____________ _____________ _____________ FORMCHECKBOX Active FORMCHECKBOX Inactive FORMCHECKBOX Exam FORMCHECKBOX Reciprocity State #8: _______ _____________ _____________ _____________ FORMCHECKBOX Active FORMCHECKBOX Inactive FORMCHECKBOX Exam FORMCHECKBOX Reciprocity If licensed in more than eight (8) states, please supply the same information on a separate sheet and attach. VI. drug enforcement administration information (dea) (This application cannot be processed without current Federal DEA Certificate for each state in which you practice) Federal DEA Certificate #: _________________________________________ Expiration: _______________________________________________ Federal DEA Certificate #: _________________________________________ Expiration: _______________________________________________ VII. state narcotics registration: controlled substance registration (csr) Some states require additional CSR certificates. Attach copies of any additional CSR certificates you have. State: _____________________________________________________________________________________________________________________ Certificate #: ____________________________________________________ Expiration: _______________________________________________ State: _____________________________________________________________________________________________________________________ Certificate #: ____________________________________________________ Expiration: _______________________________________________ VIII. professional liability data (This application cannot be processed without proof of amount of professional liability) Name of Carrier: _____________________________________________________________________________________________________________ Address: ___________________________________________________________________________________________________________________ City: ________________________________________________ State: ______________________ ZIP: _____________________________ Policy #: ____________________________________________ Amount of Coverage: ________________________________________________ Date of Inception: _____________________________________ Date of Expiration: __________________________________________________ Name of Agency: _____________________________________________________________________________________________________________ FORMCHECKBOX CLAIMS MADE FORMCHECKBOX OCCURRENCE (Check One) Please list any other professional liability carriers you have used within the last five (5) years: _________________________________________________ ____________________________________________________________________________________________________________________________ Answer the following questions: Has your professional liability insurance coverage been terminated by action of the insurance company? FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX No Have you been denied professional liability insurance coverage or been rated at a higher than average risk FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX No class for your specialty? 3. Has your present professional liability insurance carrier excluded any specific procedures from your FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX No coverage? 4. Have any professional liability suits or claims been filed against you? FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX No 5. Have any professional liability suits or claims been filed against you which are presently pending? FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX No 6. Have any judgments or settlements been made against you in professional liability cases? FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX No 7. If applying to an Indiana facility, do you participate in the Indiana Patient Compensation Fund? FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX No 8. If applying to a Virginia facility, do you participate in the Birth-related Neurological Injury Compensation Act? FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX No If the answer is yes to any of the above questions, please explain the case(s) and the outcome(s) on the following Professional Liability Detail Sheet. Provide a full explanation including the name of the carrier, the date and specific information concerning any limitation, settlement or judgment. PROFESSIONAL LIABILITY DETAIL SHEET (Please copy this page if additional sheets are needed) FORMCHECKBOX CHECK HERE IF NOT APPLICABLE Please fill in the following details for each pending or settled malpractice suit or claim you have experienced: FORMCHECKBOX Pending FORMCHECKBOX Settled Date: ____________________________ List the allegations: ___________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ Date of occurrence: ___________________________________________________________________________________________________________ Name of institution involved (i.e., hospital): _________________________________________________________________________________________ Name and address of insurance carriers involved: ___________________________________________________________________________________ Please supply the following details for each malpractice lawsuit in which you were a defendant, and which resulted in a jury award or court judgments against you. Title of the court case: _________________________________________________________________________________________________________ The court case number: ________________________________________________________________________________________________________ The venue of the case (place where court case took place, such as County District Court or Circuit Court): ______________________________________ ____________________________________________________________________________________________________________________________ Allegations listed in complaint: __________________________________________________________________________________________________ Date of incident leading to complaint: _____________________________________________________________________________________________ Place of incident: _____________________________________________________________________________________________________________ Name and address of malpractice insurance carrier: _________________________________________________________________________________ ____________________________________________________________________________________________________________________________ Amount of jury award or amount awarded by the court: _______________________________________________________________________________ IX. certification by american board of medical specialties or american osteopathic association (Allied Health Professional: list national certifications) Are you board certified? FORMCHECKBOX Yes FORMCHECKBOX No (If not Board admissible, please explain on separate sheet and attach) If yes, list full name of certifying board and date which you obtained certification/recertification: _____________________________________________________________________________ Date: ____________________________ _____________________________________________________________________________ Date: ____________________________ _____________________________________________________________________________ Date: ____________________________ _____________________________________________________________________________ Date: ____________________________ _____________________________________________________________________________ Date: ____________________________ 3. If you are not yet certified but have applied to a specialty board for examination, give the name of the board and date of application: _____________________________________________________________________________ Date: ____________________________ 4. If status is one of eligibility, provide year when eligibility will terminate under rules of the specific board: _____________________________________ 5. List date of next required recertification (if applicable): ____________________________________________________________________________ 6. Have you ever been examined by a specialty board but failed to pass the exam? If yes, please explain. FORMCHECKBOX Yes FORMCHECKBOX No X. individual practice information Please answer each of the following questions in full. If the answer to any question is "yes," please provide full explanation of the details on a separate sheet and attach. 1. Are there any actions that have been initiated or are any pending against you by any state licensing board? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Pending FORMCHECKBOX Resolved 2. Have you had any professional license or certification in any state that has ever been denied, limited, FORMCHECKBOX Yes FORMCHECKBOX No suspended, sanctioned, revoked, probated, voluntarily or involuntarily relinquished or not renewed? 3. Have you ever received notice of a proposed or actual exclusion (suspension, sanction, otherwise restricted) FORMCHECKBOX Yes FORMCHECKBOX No from any private health care program(s) or any health care program(s) funded in whole or in part by the state or federal government, including Medicare or Medicaid? If so, provide a detailed description of this matter, including the current status of your participation in such program(s). 4. Have you ever been the subject of an investigation by any private, federal or state agency concerning your FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX No participation in any private, federal or state health insurance program? Have your narcotics registration certificates ever been limited, suspended, revoked, voluntarily or FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX No involuntarily surrendered or not renewed? 6. If applicable, is your federal (to include District of Columbia and territories of U.S.A. ) and/or state narcotics FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX No registration certificate being challenged? 7. Have you been named as a defendant or convicted of a felony or misdemeanor? FORMCHECKBOX Yes FORMCHECKBOX No 8. Have your employment, medical staff appointment or clinical privileges ever been voluntarily or involuntarily FORMCHECKBOX Yes FORMCHECKBOX No denied, suspended, diminished, revoked, limited or not renewed at any health care facility? 9. Have you ever withdrawn your application for appointment, reappointment, clinical privileges, or resigned FORMCHECKBOX Yes FORMCHECKBOX No from the medical staff of any health care facility before a decision was made by its governing board? 10. Have you ever been the subject of disciplinary proceedings or a focus review based on inappropriate FORMCHECKBOX Yes FORMCHECKBOX No quality of care at any hospital or health care facility? 11. Have you ever been denied membership or renewal thereof, or been subject to disciplinary or adverse FORMCHECKBOX Yes FORMCHECKBOX No action in any medical or professional organization? XI. personal health status Please answer each of the following questions in full. If the answer to any question is "yes," please provide full explanation of the details on the appropriate Explanation Sheet. 1. Do you currently have, or have you ever had any physical, mental, or emotional condition which impaired, or might FORMCHECKBOX Yes FORMCHECKBOX No reasonably be considered to impair, your ability to perform the procedures or provide the treatment for which you have requested clinical privileges or to meet the requirements of medical staff membership? 2. Have you ever been admitted to any hospital or been involved in a treatment program for any physical, mental or FORMCHECKBOX Yes FORMCHECKBOX No emotional condition which impaired or might reasonably be considered to impair, your ability to perform the procedures or provide the treatment for which you have requested clinical privileges or to meet the requirements of medical staff membership? 3. Do you currently have, or have you ever had a dependency on or abuse of the use of alcohol or drugs, or are you FORMCHECKBOX Yes FORMCHECKBOX No currently or have ever been involved in a treatment program for a dependency on or abuse of alcohol or drugs which impaired, or might reasonably be considered to impair, your ability to perform the procedures or provide the treatment for which you have requested clinical privileges or to meet the requirements of medical staff membership? XII. professional societies Membership in local, state, or national medical societies Dates Name: _________________________________________________________________________________ _____________ / _____________ From (mm/ yy ) To (mm/ yy ) Address: ____________________________________________________________________________________________________________ City: ________________________________________________ State: ______________________ ZIP: ______________________ Name: _________________________________________________________________________________ _____________ / _____________ From (mm/ yy ) To (mm/ yy ) Address: ____________________________________________________________________________________________________________ City: ________________________________________________ State: ______________________ ZIP: ______________________ Name: _________________________________________________________________________________ _____________ / _____________ From (mm/ yy ) To (mm/ yy ) Address: ____________________________________________________________________________________________________________ City: ________________________________________________ State: ______________________ ZIP: ______________________ Name: _________________________________________________________________________________ _____________ / _____________ From (mm/ yy ) To (mm/ yy ) Address: ____________________________________________________________________________________________________________ City: ________________________________________________ State: ______________________ ZIP: ______________________ 1. I would like to use this application for membership in the __________________________________ County Medical Society and the KMA. A separate dues statement will be sent. 2. I am already a member of my local medical society. Please specify society: _____________________________________________________ XIII. professional Employment and affiliations A. Employment List in chronological order all professional employment since completion of post-graduate education, starting with your current position. This includes all hospitals, corporations, military assignments, government agencies, group practices, other healthcare facilities or other types of activity. Complete addresses must be included. Date must be in MM/YY format. If you have a gap in employment of more than thirty (30) days, please explain on a separate page. "See CV" is not acceptable. Please attach additional sheets if more space is needed. Name: ________________________________________________ Department: __________________________ _____________ / _____________ From (mm/ yy ) To (mm/ yy ) Address: __________________________________________________________ Type of Privileges/Position: _______________________________ City/St/ZIP: _______________________________________________________________________________________________________________ City St ZIP ZIP + Country Phone: _________________________ Fax: _________________________ Email (if available): ________________________________________ Reason for leaving: ________________________________________________________________________________________________________ Name: ________________________________________________ Department: __________________________ _____________ / _____________ From (mm/ yy ) To (mm/ yy ) Address: __________________________________________________________ Type of Privileges/Position: _______________________________ City/St/ZIP: _______________________________________________________________________________________________________________ City St ZIP ZIP + Country Phone: _________________________ Fax: _________________________ Email (if available): ________________________________________ Reason for leaving: ________________________________________________________________________________________________________ Name: ________________________________________________ Department: __________________________ _____________ / _____________ From (mm/ yy ) To (mm/ yy ) Address: __________________________________________________________ Type of Privileges/Position: _______________________________ City/St/ZIP: _______________________________________________________________________________________________________________ City St ZIP ZIP+ Country Phone: _________________________ Fax: _________________________ Email (if available): ________________________________________ Reason for leaving: ________________________________________________________________________________________________________ Name: ________________________________________________ Department: __________________________ _____________ / _____________ From (mm/ yy ) To (mm/ yy ) Address: __________________________________________________________ Type of Privileges/Position: _______________________________ City/St/ZIP: _______________________________________________________________________________________________________________ City St ZIP ZIP + Country Phone: _________________________ Fax: _________________________ Email (if available): ________________________________________ Reason for leaving: ________________________________________________________________________________________________________ B. Affiliations List in chronological order all professional affiliations since completion of post-graduate education, starting with your current position. This includes all hospitals, corporations, military assignments, government agencies, group practices, other healthcare facilities or other types of activity. Complete addresses must be included. Date must be in MM/YY format. If you have a gap in employment of more than thirty (30) days, please explain on a separate page. "See CV" is not acceptable. Please attach additional sheets if more space is needed.