Chiropractor_AF_Form_1540_20160310.pdf

APPLICATION FOR CLINICAL PRIVILEGES / MEDICAL STAFF APPOINTMENT

AUTHORITY: Title 10 U.S.C. Chapter 55 and Sections 1094 and 1102.

PRINCIPAL PURPOSE: To evaluate professional criteria for medical staff membership and clinical privileges; designed to help establish an applicant's background, current competence, and physical and mental ability to discharge patient care responsibilities. This evaluation is essential to establishing and maintaining a qualified, competent medical staff.

ROUTINE USE: Information on this form may be released to government boards or agencies, or to professional societies or organizations, if needed to license or monitor professional standards of health care providers. It may also be released to civilian medical institutions or organizations where the provider is applying for staff privileges during or after separating from the Air Force.

DISCLOSURE IS VOLUNTARY: However, failure to provide information may result in the limitation or termination of clinical privileges.

APPLICANT COMPLETES SECTION I THROUGH X

(All date entries must be entered as YYYYMMDD)I. IDENTIFICATION

NAME (Last) (First) (MI) DATE OF BIRTH GRADE SSN DATE (YYYYMMDD)

ALIAS (i.e., Maiden) HOME PHONE HOME ADDRESS (Street, City, State, ZIP Code, Country) DUTY PHONE EMAIL ADDRESS

ORGANIZATION / OFFICE SYMBOL DUTY SECTION DAFSC PAFSC CORPS

SOURCE OF ACCESSION

Baccalaureate Degree Completion Program (BDCP) Reserve Officer Training Corps (ROTC) Civilian Civil Service

Direct Accession (DA) Uniformed Services Univ. of Health Sciences (USUHS) Civilian Contractor

Enlisted Commissioning Program (ECP) National Guard Civilian Consultant

Financial Assistance Program (FAP) Reserve Civilian Volunteer

Health Professional Scholarship Program (HPSP) Foreign National Other:

(Undergraduate / Graduate / Professional)II. PROFESSIONAL EDUCATION

DATES ATTENDEDNAME OF

PROFESSIONAL SCHOOL LOCATION DEGREE

FROM TO

(Internship, Residency, Fellowships)III. POST GRADUATE TRAINING

DATES ATTENDED

NAME OF INSTITUTION LOCATION TYPE OF PROGRAM (Residency, etc.)

FROM TO

(If additional space is needed, continue on Page 2)IV. PRESENT AND PREVIOUS MILITARY AND CIVILIAN ASSIGNMENTS

DATES ASSIGNEDSERVICE OR SPECIALTY

TO WHICH ASSIGNED

NAME OF MEDICAL TREATMENT

FACILITY (MTF) OR ORGANIZATION LOCATION

FROM TO

PREVIOUS EDITION IS OBSOLETE. PAGE 1 OF 4 PAGESAF IMT 1540, 20040819, V1

(Continued)APPLICATION FOR CLINICAL PRIVILEGES / MEDICAL STAFF APPOINTMENT (If additional space is needed, continue in Remarks, Page 4.)(Continued)IV. PRESENT AND PREVIOUS MILITARY AND CIVILIAN ASSIGNMENTS

SERVICE OR SPECIALTY

TO WHICH ASSIGNED

DATE ASSIGNEDNAME OF MEDICAL TREATMENT

FACILITY (MTF) OR ORGANIZATION LOCATION FROM TO

(Additional space is available in Remarks, Page 4)V. LICENSE/CERTIFICATION/REGISTRATION, SPECIALTY, & FEDERAL DEA/STATE CSR (Must list ALL ever held.)LICENSE / CERTIFICATION / REGISTRATION

DATE ISSUED EXPIRATION DATELICENSE NUMBER

DATE ISSUED EXPIRATION DATENATIONAL CERTIFICATION CERTIFICATE NUMBER

DATE ISSUED EXPIRATION DATENATIONAL REGISTRATION REGISTRATION NUMBER

SPECIALTY DATA

DATE ISSUED EXPIRATION DATECERTIFICATE NUMBER

FEDERAL DRUG ENFORCEMENT ADMINISTRATION (DEA) / STATE CONTROLLED SUBSTANCE REGISTRATION (CSR)

DATE ISSUED EXPIRATION DATEREGISTRATION NUMBER

DoD Fee-Exempt

Federal (Fee-Paid)

DATE ISSUED EXPIRATION DATEREGISTRATION NUMBER

VI.

(Member, Fellow, etc.)NAME OF SOCIETY STATUS

(Every applicant MUST list three references: former clinical supervisor; chief, medical staff (SGH); and peer) (List email address if available)VII. REFERENCES TELEPHONE NUMBER & EMAIL ADDRESSNAME ADDRESS (City/Base, State, Zip Code)

PAGE 2 OF 4 PAGESAF IMT 1540, 20040819, V1

STATUS (active, expired, etc.)STATE LICENSE (Name of State)

STATUS (active, expired, etc.)

STATUS (active, expired, etc.)

SPECIALTY (List all specialties for which fully qualified)

BOARD CERTIFICATION (Specialty Board)

FEDERAL DEA (Type)

STATE CSR (Name of State)

MEMBERSHIP IN PROFESSIONAL SOCIETIES (If additional space is needed, continue in Remarks, Page 4)

VIII.

YES NO YES NOHave there been previously successful or currently pending challenges, revocations, or restrictions to any license, certification, or registration (state, district, or Drug Enforcement Administration) to practice in any jurisdiction, or the voluntary/involuntary relinquishment of such license, certification, or registration?

Have you ever been a defendent or the subject of a medical malpractice liability claim, settlement, judicial or administrative adjudication, or any other resolved or unresolved allegations of inappropriate, unethical, unprofessional, or substandard care?

A. E.

Have you ever had a voluntary or involuntary limitation, reduction, revocation, suspension, denial, or loss of clinical privileges?

B. IF "YES" WAS THE RESPONSE:

Settled prior to final court action?(1) Have you ever voluntarily or involuntarily terminated or been denied medical staff membership or membership in a professional group or society?

C.

Judgement rendered by court?(2)

Defendant found liable?(3)Have you ever been a defendent in a felony or misdemeanor case?

D.

Matter still pending?(4)(Indicate final disposition of case in Remarks, Page 4)

IX.

YES NO YES NOHave you ever been hospitalized for, or diagnosed with, a psychiatric disorder to include substance abuse?

A. E.

Are you currently under or have you ever received treatments for an alcohol or drug-related condition?

B. Are you currently taking any medication? F.

C. Do you have a potentially communicable disease?

Have you ever used a controlled substance that was not prescribed for you by a physician or other health care provider?

G.Have you ever been hospitalized for any reason in the past 5 years?

D.

(PLEASE READ CAREFULLY BEFORE SIGNING)X. STATEMENT OF APPLICANT

I certify all information submitted by me in this application is true to the best of my knowledge and belief and I have the ability to perform the clinical privileges requested.

I consent to the inspection of all records and documents pertinent to my licensure, specific training, experience, current competence, and ability to perform the privileges requested, and, if requested, appear for an interview.

I certify that any false or incomplete information knowingly provided on or with this application may be grounds either for not employing or accessing me or for dismissing or releasing me if I am already employed or serving. I understand that knowingly providing false or incomplete information is punishable by fine or imprisonment under United States Code Title 18, Section 1001.

I agree to release and hold harmless from any liability the United States and any and all persons who participate within the scope of their duties in good faith and without malice in the review of any action or recommendation relating to my application.

In making this application for clinical privileges, I acknowledge my responsibility to provide for the continuous care of my patients.

I understand and agree that I, as an applicant for clinical 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 authorize all who may have information bearing on my professional qualifications, ethical standing, competence, and mental and physical health status to release the aforementioned information to the designated healthcare organization, their staff, and agents. This includes individuals, institutions, and entities of organizations with which I am currently or have been associated, and all professional liability insurers with which I have had or currently have professional liability insurance.

I acknowledge that I am familiar with the principles and standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and will cooperate in maintaining JCAHO standards.

I agree to subject my clinical performance to, and faithfully participate in, activities to measure, assess, and improve performance on an organization-wide basis.

SIGNATURE OF APPLICANT DATE

PAGE 3 OF 4 PAGESAF IMT 1540, 20040819, V1

PRACTICE HISTORY (Explain all "YES" responses in Remarks, Page 4)

HEALTH STATUS (Explain all "YES" responses in Remarks, Page 4)

Do you currently have any physical or mental impairment that could limit your clinical practice?

APPLICATION FOR CLINICAL PRIVILEGES / MEDICAL STAFF APPOINTMENT (Continued)

I have been informed that the medical staff bylaws, rules, and regulations (AFI 44-119, Clinical Performance Improvement) can be accessed at the following internet site:

http://www.e-publishing.af.mil/ and agree that my activities as a medical staff member will be bound by these bylaws.

FOR CREDENTIALS FUNCTION USE ONLY

TYPE OF CLINICAL PRIVILEGES

Regular Privileges Supervised Privileges Temporary Privileges

TYPE OF MEDICAL STAFF APPOINTMENT

Initial - Active Medical Staff Appointment Active Medical Staff Appointment No Medical Staff Appointment

Affiliate Medical Staff Appointment Temporary Medical Staff AppointmentInitial - Affiliate Medical Staff Appointment

XI. CLINICAL SUPERVISOR RECOMMENDATION

I have reviewed the provider's clinical privileges and confirm his/her physical and mental ability and qualifications to perform the requested privileges.

1 1CLINICAL PRIVILEGES: Approval Approval with Modification Disapproval 1 1MEDICAL STAFF PRIVILEGES: Approval Approval with Modification Disapproval

SIGNATURE OF CLINICAL SUPERVISOR (USE NAME STAMP OR TYPE NAME AND TITLE) DATE

XII. DEPARTMENT CHAIR / CHIEF OF SERVICE RECOMMENDATION

1 1CLINICAL PRIVILEGES: Approval Approval with Modification Disapproval

1 1MEDICAL STAFF PRIVILEGES: Approval Approval with Modification Disapproval

SIGNATURE OF DEPARTMENT CHAIR / CHIEF OF SERVICE (USE NAME STAMP OR TYPE NAME AND TITLE) DATE

XIII.

1 1CLINICAL PRIVILEGES: Approval Approval with Modification Disapproval

1 1MEDICAL STAFF PRIVILEGES: Approval Approval with Modification Disapproval

SIGNATURE OF CREDENTIAL FUNCTION CHAIRPERSON (USE NAME STAMP OR TYPE NAME AND TITLE) DATE

XIV. MEDICAL FACILITY COMMANDER APPROVAL

1 1Approval Approval with Modification Disapproval

SIGNATURE OF MEDICAL FACILITY COMMANDER (USE NAME STAMP OR TYPE NAME AND TITLE) DATE

(If additional space is needed, continue on plain bond paper):REMARKS

1(Note Explain in "Remarks" on this page.)

PAGE 4 OF 4 PAGESAF IMT 1540, 20040819, V1

APPLICATION FOR CLINICAL PRIVILEGES / MEDICAL STAFF APPOINTMENT (Continued)

CREDENTIAL FUNCTION CHAIRPERSON (SGH) RECOMMENDATION

APPLICATION FOR CLINICAL PRIVILEGES / MEDICAL STAFF APPOINTMENT

AUTHORITY: Title 10 U.S.C. Chapter 55 and Sections 1094 and 1102.

PRINCIPAL PURPOSE: To evaluate professional criteria for medical staff membership and clinical privileges; designed to help establish an applicant's background, current competence, and physical and mental ability to discharge patient care responsibilities. This evaluation is essential to establishing and maintaining a qualified, competent medical staff.

ROUTINE USE: Information on this form may be released to government boards or agencies, or to professional societies or organizations, if needed to license or monitor professional standards of health care providers. It may also be released to civilian medical institutions or organizations where the provider is applying for staff privileges during or after separating from the Air Force.

DISCLOSURE IS VOLUNTARY: However, failure to provide information may result in the limitation or termination of clinical privileges.

APPLICANT COMPLETES SECTION I THROUGH X

(All date entries must be entered as YYYYMMDD) I.

IDENTIFICATION

NAME (Last) (First)

(MI)

DATE OF BIRTH

GRADE

SSN

DATE (YYYYMMDD)

ALIAS (i.e., Maiden)

HOME PHONE

HOME ADDRESS (Street, City, State, ZIP Code, Country)

DUTY PHONE

EMAIL ADDRESS

ORGANIZATION / OFFICE SYMBOL

DUTY SECTION

DAFSC

PAFSC

CORPS

SOURCE OF ACCESSION

Baccalaureate Degree Completion Program (BDCP) Reserve Officer Training Corps (ROTC) Civilian Civil Service Direct Accession (DA) Uniformed Services Univ. of Health Sciences (USUHS) Civilian Contractor Enlisted Commissioning Program (ECP) National Guard Civilian Consultant Financial Assistance Program (FAP) Reserve Civilian Volunteer Health Professional Scholarship Program (HPSP) Foreign National Other:

(Undergraduate / Graduate / Professional)

II.

PROFESSIONAL EDUCATION

DATES ATTENDED

NAME OF

PROFESSIONAL SCHOOL

LOCATION

DEGREE

FROM

TO

(Internship, Residency, Fellowships)

III.

POST GRADUATE TRAINING

DATES ATTENDED

NAME OF INSTITUTION

LOCATION

TYPE OF PROGRAM

(Residency, etc.)

FROM

TO

(If additional space is needed, continue on Page 2)

IV.

PRESENT AND PREVIOUS MILITARY AND CIVILIAN ASSIGNMENTS

DATES ASSIGNED

SERVICE OR SPECIALTY

TO WHICH ASSIGNED

NAME OF MEDICAL TREATMENT

FACILITY (MTF) OR ORGANIZATION

LOCATION

FROM

TO

PREVIOUS EDITION IS OBSOLETE.

PAGE 1 OF 4 PAGES

AF IMT 1540, 20040819, V1

(Continued)

APPLICATION FOR CLINICAL PRIVILEGES / MEDICAL STAFF APPOINTMENT

(If additional space is needed, continue in Remarks, Page 4.)

(Continued)

IV.

PRESENT AND PREVIOUS MILITARY AND CIVILIAN ASSIGNMENTS

SERVICE OR SPECIALTY

TO WHICH ASSIGNED

DATE ASSIGNED

NAME OF MEDICAL TREATMENT

FACILITY (MTF) OR ORGANIZATION

LOCATION

FROM

TO

(Additional space is available in Remarks, Page 4)

V. LICENSE/CERTIFICATION/REGISTRATION, SPECIALTY, & FEDERAL DEA/STATE CSR

(Must list ALL ever held.)

LICENSE / CERTIFICATION / REGISTRATION

DATE ISSUED

EXPIRATION DATE

LICENSE NUMBER

DATE ISSUED

EXPIRATION DATE

NATIONAL CERTIFICATION

CERTIFICATE NUMBER

DATE ISSUED

EXPIRATION DATE

NATIONAL REGISTRATION

REGISTRATION NUMBER

SPECIALTY DATA

DATE ISSUED

EXPIRATION DATE

CERTIFICATE NUMBER

FEDERAL DRUG ENFORCEMENT ADMINISTRATION (DEA) / STATE CONTROLLED SUBSTANCE REGISTRATION (CSR)

DATE ISSUED

EXPIRATION DATE

REGISTRATION NUMBER

DoD Fee-Exempt Federal (Fee-Paid)

DATE ISSUED

EXPIRATION DATE

REGISTRATION NUMBER

VI.

(Member, Fellow, etc.)

NAME OF SOCIETY

STATUS

(Every applicant MUST list three references: former clinical supervisor; chief, medical staff (SGH); and peer) (List email address if available)

VII. REFERENCES

TELEPHONE NUMBER & EMAIL ADDRESS

NAME

ADDRESS

(City/Base, State, Zip Code)

PAGE 2 OF 4 PAGES

AF IMT 1540, 20040819, V1

STATUS (active, expired, etc.)

STATE LICENSE (Name of State) STATUS (active, expired, etc.)

STATUS (active, expired, etc.)

SPECIALTY (List all specialties for which fully qualified) BOARD CERTIFICATION (Specialty Board) FEDERAL DEA (Type) STATE CSR (Name of State) MEMBERSHIP IN PROFESSIONAL SOCIETIES (If additional space is needed, continue in Remarks, Page 4)

VIII.

YES

NO

YES

NO

Have there been previously successful or currently pending challenges, revocations, or restrictions to any license, certification, or registration (state, district, or Drug Enforcement Administration) to practice in any jurisdiction, or the voluntary/involuntary relinquishment of such license, certification, or registration?

Have you ever been a defendent or the subject of a medical malpractice liability claim, settlement, judicial or administrative adjudication, or any other resolved or unresolved allegations of inappropriate, unethical, unprofessional, or substandard care?

A.

E.

Have you ever had a voluntary or involuntary limitation, reduction, revocation, suspension, denial, or loss of clinical privileges?

B.

IF "YES" WAS THE RESPONSE:

Settled prior to final court action?

(1) Have you ever voluntarily or involuntarily terminated or been denied medical staff membership or membership in a professional group or society?

C.

Judgement rendered by court?

(2) Defendant found liable?

(3) Have you ever been a defendent in a felony or misdemeanor case?

D.

Matter still pending?

(4) (Indicate final disposition of case in Remarks, Page 4)

IX.

YES

NO

YES

NO

Have you ever been hospitalized for, or diagnosed with, a psychiatric disorder to include substance abuse?

A.

E.

Are you currently under or have you ever received treatments for an alcohol or drug-related condition?

B. Are you currently taking any medication?

F.

C. Do you have a potentially communicable disease?

Have you ever used a controlled substance that was not prescribed for you by a physician or other health care provider?

G.

Have you ever been hospitalized for any reason in the past 5 years?

D.

(PLEASE READ CAREFULLY BEFORE SIGNING)

X.

STATEMENT OF APPLICANT

I certify all information submitted by me in this application is true to the best of my knowledge and belief and I have the ability to perform the clinical privileges requested.

I consent to the inspection of all records and documents pertinent to my licensure, specific training, experience, current competence, and ability to perform the privileges requested, and, if requested, appear for an interview.

I certify that any false or incomplete information knowingly provided on or with this application may be grounds either for not employing or accessing me or for dismissing or releasing me if I am already employed or serving. I understand that knowingly providing false or incomplete information is punishable by fine or imprisonment under United States Code Title 18, Section 1001.

I agree to release and hold harmless from any liability the United States and any and all persons who participate within the scope of their duties in good faith and without malice in the review of any action or recommendation relating to my application.

In making this application for clinical privileges, I acknowledge my responsibility to provide for the continuous care of my patients.

I understand and agree that I, as an applicant for clinical 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 authorize all who may have information bearing on my professional qualifications, ethical standing, competence, and mental and physical health status to release the aforementioned information to the designated healthcare organization, their staff, and agents. This includes individuals, institutions, and entities of organizations with which I am currently or have been associated, and all professional liability insurers with which I have had or currently have professional liability insurance.

I acknowledge that I am familiar with the principles and standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and will cooperate in maintaining JCAHO standards.

I agree to subject my clinical performance to, and faithfully participate in, activities to measure, assess, and improve performance on an organization-wide basis.

SIGNATURE OF APPLICANT

DATE

PAGE 3 OF 4 PAGES

AF IMT 1540, 20040819, V1

PRACTICE HISTORY (Explain all "YES" responses in Remarks, Page 4)

HEALTH STATUS

(Explain all "YES" responses in Remarks, Page 4) Do you currently have any physical or mental impairment that could limit your clinical practice?

APPLICATION FOR CLINICAL PRIVILEGES / MEDICAL STAFF APPOINTMENT (Continued) I have been informed that the medical staff bylaws, rules, and regulations (AFI 44-119, Clinical Performance Improvement) can be accessed at the following internet site:

http://www.e-publishing.af.mil/ and agree that my activities as a medical staff member will be bound by these bylaws.

FOR CREDENTIALS FUNCTION USE ONLY

TYPE OF CLINICAL PRIVILEGES

Regular Privileges Supervised Privileges Temporary Privileges

TYPE OF MEDICAL STAFF APPOINTMENT

Initial - Active Medical Staff Appointment Active Medical Staff Appointment No Medical Staff Appointment Affiliate Medical Staff Appointment Temporary Medical Staff Appointment Initial - Affiliate Medical Staff Appointment

XI.

CLINICAL SUPERVISOR RECOMMENDATION

I have reviewed the provider's clinical privileges and confirm his/her physical and mental ability and qualifications to perform the requested privileges.

CLINICAL PRIVILEGES:

Approval Approval with Modification Disapproval

MEDICAL STAFF PRIVILEGES:

Approval Approval with Modification Disapproval

SIGNATURE OF CLINICAL SUPERVISOR (USE NAME STAMP OR TYPE NAME AND TITLE)

DATE

XII.

DEPARTMENT CHAIR / CHIEF OF SERVICE RECOMMENDATION

CLINICAL PRIVILEGES:

Approval Approval with Modification Disapproval

MEDICAL STAFF PRIVILEGES:

Approval Approval with Modification Disapproval SIGNATURE OF DEPARTMENT CHAIR / CHIEF OF SERVICE (USE NAME STAMP OR TYPE NAME AND TITLE)

DATE

XIII.

CLINICAL PRIVILEGES:

Approval Approval with Modification Disapproval

MEDICAL STAFF PRIVILEGES:

Approval Approval with Modification Disapproval SIGNATURE OF CREDENTIAL FUNCTION CHAIRPERSON (USE NAME STAMP OR TYPE NAME AND TITLE)

DATE

XIV.

MEDICAL FACILITY COMMANDER APPROVAL

Approval Approval with Modification Disapproval

SIGNATURE OF MEDICAL FACILITY COMMANDER (USE NAME STAMP OR TYPE NAME AND TITLE)

DATE

(If additional space is needed, continue on plain bond paper):

REMARKS

(Note Explain in "Remarks" on this page.)

PAGE 4 OF 4 PAGES

AF IMT 1540, 20040819, V1

APPLICATION FOR CLINICAL PRIVILEGES / MEDICAL STAFF APPOINTMENT (Continued)

CREDENTIAL FUNCTION CHAIRPERSON (SGH) RECOMMENDATION

8.2.1.3158.1.475346.466429