Podiatry Services Credentialing Process and Application - Attachment A.docx

The following items are needed to perform the credentialing process:

1. Application

2. Kaper

3. 3 Med Staff Evaluations, including typed letters of reference from those filling out the evaluations

4. Copy of Driver’s License

5. Copy of Social Security Card

6. Copy of Medical License/APRN License

7. Copy of board certificates

8. Copy of med school/APRN certificates

9. Copy of liability insurance

10. Signed and dated CV

11. Copy of CME’s

12. Copy of DEA

13. 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

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

action under circumstances specified in the medical staff

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:

A. New Appointees: Based on review of previous employer assessments.

B. 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:

A. New Appointees: Based on review of physical examinations and previous employer assessments.

B. Renewals: Physical and mental ability to carry out staff responsibilities as determined through personal observations and quality care monitoring.

IKAPER-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

|_| Medical Staff |_| Allied Health (please specify) ________________________________________________________________

Credentialing Contact: Amanda Knight______________________________________ Credentialing Email: amandaj.knight@ky.gov________

Preferred Mailing Address: |_| Primary Office |_| Residence |_| 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 #: ______________________|_| Alpha |_| Digital |_| 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: |_| Solo |_| Group |_| Partnership |_| 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. |_| Yes |_| 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.

|_| Yes |_| 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.

|_| Yes |_| No |_| 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? |_| Yes |_| 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.

|_| Yes |_| 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? |_| Yes |_| 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.

|_| Yes |_| 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? |_| Yes |_| 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.

|_| Yes |_| No

|_| 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? |_| Yes |_| 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.

|_| Yes |_| 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? |_| Yes |_| 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.

|_| Yes |_| 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? |_| Yes |_| 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.

|_| Yes |_| No

|_| 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: ____________________________________________________________________________________________________________________

|_| 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.

|_| YES |_| NO |_| List and/or certificates attached

Do you have a cardio-pulmonary resuscitation certificate?

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.

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: _____________________________________________________________________________________________________________

|_| CLAIMS MADE |_| OCCURRENCE (Check One)

Please list any other professional liability carriers you have used within the last five (5) years: _________________________________________________

Answer the following questions:

class for your specialty?

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)

|_| CHECK HERE IF NOT APPLICABLE

Please fill in the following details for each pending or settled malpractice suit or claim you have experienced:

|_| Pending |_| 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)

1. Are you board certified? |_| Yes |_| No (If not Board admissible, please explain on separate sheet and attach)

2. If yes, list full name of certifying board and date which you obtained certification/recertification:

4. If status is one of eligibility, provide year when eligibility will terminate under rules of the specific board: _____________________________________

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.

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) |_| Yes |_| 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 |_| N/A |_| Yes |_| No participation in any private, federal or state health insurance program?

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 |_| Yes |_| 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 |_| Yes |_| 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 |_| Yes |_| 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.

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: ______________________

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.

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: ________________________________________________________________________________________________________

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: ________________________________________________________________________________________________________

XIV. PEER REFERENCES

Name three physicians who have personal knowledge of your current clinical abilities, and ethical character, who will provide specific written comments on these matters upon request from Hospitals, Medical Societies, or Authorized Credentialing Services. The named individuals must have acquired the requisite knowledge through recent observation of your professional practice over a reasonable period of time, and at least one must have had organizational responsibility for your performance. The individuals should not be related to you by blood or marriage, training directors, partners/associates in your current group practice, or anyone with whom you have or anticipate having a financial relationship. Requested sources: practitioner in same specialty or practitioners with whom you have a referral pattern. If you recently completed training, you may use chief resident or other training colleague.