INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF 07/09/2015

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INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF
Dear:
Date: 07/09/2015
We are pleased to provide you with the enclosed Vanderbilt University Medical Center (VUMC) Initial
Appointment Application for Professional Staff. This packet includes the application for Professional Staff
membership and clinical privileges (as applicable). This “one packet” is used to expedite both the
appointment of qualified applicants to the Medical Staff and enrollment with Vanderbilt Medical Group
(VMG) contracted healthcare plans as applicable.
The Medical Staff Bylaws and Rules & Regulations may be found at the following site:
https://vanderbilt.policytech.com/
Please review these documents as you will be expected to abide by them and agree to do so by signing
the Acknowledgement and Signature form located at the end of this application.
SA
Your application will be considered complete and ready for processing once all requested information has
been received in the Provider Support Services (PSS) office and your Faculty Appointment (for billing
providers) with the School of Medicine or School of Nursing has been verified. The submission of your
application for membership does not automatically grant you Professional Staff membership
and privileges. All applications must proceed through a verification and review process and must also be
approved by the governing body.
Once your completed, signed, and dated application is received in the Provider Support Services office, the
credentialing process may begin. The credentialing process generally takes 90 days, however in
order to reach this 90 day benchmark, we recommend the following:
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Provide Complete, Detailed Information – Complete all areas of the application, providing as much
detail as possible. Do not refer to documents such as your CV or resume. Incomplete applications
cannot be processed and will be returned to the applicant for completion. If additional space is
required to provide all of the information required, please submit additional files or pages with your
application.
Provide Accurate Information - The process may require less time if contact information, including
accurate mailing addresses, telephone numbers, fax numbers and e-mail addresses is provided.
Be prepared to help – Your assistance may be required when, after several attempts, we are unable
to obtain a response from a primary source.
This application can only be completed electronically using Adobe Reader or Acrobat. Your application
must be printed to be signed and submitted.
Please do not sign or date documents until you submit your application. If your application is
not approved by the Credentials Committee within 120 days from the date of signature your
application will expire and a new application will have to be submitted, restarting the credentialing
process.
PL
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If we can further assist you in this process, please contact Provider Support Services at (615) 322-3573.
To Submit your application: DO NOT RETURN VIA CAMPUS MAIL
Ship USPS, FedEx, or UPS to:
Provider Support Services
1500 21st Avenue South, Room 4163
Scan and email your application to PSS securely
via Accellion:
[email protected]
FAX to: 615-343-8711
Nashville, TN 37212
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
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INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF
REQUIRED DOCUMENTS CHECKLIST
The following documents are required for all practitioners in order to fully process your application. If any
of the documents listed below are not available at the time of submission of your application, please
submit your application with a note indicating when the documents will be submitted separately.
NOTE: If you do not have a TN license, documentary evidence of submission of application must be
provided prior to submitting this paperwork. Failure to do so will result in a delay in processing your
application.
PL
M
SA
… Copy of advanced degree diploma (i.e., MSN, Ph.D., etc.) and any additional Advanced Training
Certificates
… Copy of current Curriculum Vitae outlining education and practice history
o All date entries must be complete and include “From/To” and “MM/YY” information.
o Gaps in time greater than 30 days require a written explanation
… Copy of current (unexpired) U.S. Government issued photo ID (i.e., driver’s license, passport)
… Copy of SIGNED social security card
… Copy of unexpired resuscitation certification (ACLS, BLS, Advanced Airway) as applicable
… Copy of current malpractice/professional liability insurance certificate. If clinical faculty and not
receiving coverage through Vanderbilt Self Insurance Trust Fund, please provide evidence of
professional liability coverage.
… Copy of current Federal DEA Registration Certificate (as applicable)
… Copy of DD214 (as applicable)
… Copy(ies) of Board Certification/Recertification (as applicable)
… Copy of NPI assignment letter
… Copy of faculty appointment letter for billing providers (facilitated by Department and separate from
credentialing and privileging)
… Copy(ies) of Notice and Formulary signed by all Supervising Physicians or the designated Primary
Supervising Physician (if applicable).
… Complete, signed, and dated Protocol Signature Sheet (as applicable)
…
…
…
…
…
Post Graduate Education and Training (Section G)
Work History (See Section I)
Professional Liability/Malpractice (See Section J)
Licensure (Section L)
Disclosure Information (See Section M)
E
Questions in the sections below may require that you provide full details by submitting additional pages or
files with your application. Additional pages or files should also be submitted with your application as
necessary to provide complete information if there is not sufficient space within this form.
All sections of the Initial Application for Professional Staff must be completed. Sections that contain
references to Curriculum Vitae (CV) only, or those left blank will be returned for completion. Sections
which are not applicable must be marked “N/A”.
NOTE: The faculty appointment process is separate from the credentialing and privileging process, and is
facilitated by your department. Please contact them directly for information regarding faculty
appointments. A faculty appointment must be granted prior to being considered for Professional Staff
Membership.
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
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INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF
APPLICATION FOR INITIAL APPOINTMENT TO THE PROFESSIONAL STAFF
A. PERSONAL INFORMATION
Name should be listed as it appears on your license
First Name
Middle Name
Last Name
Social Security Number
Degree
Date of Birth
Suffix
Other Names by which you have been known
Maiden
Birthplace
Birth City
Birth State
Marital Status
Spouse/Partner Name
Former
Other
Birth Country
‫ ܆‬Single ‫ ܆‬Married ‫ ܆‬Divorced ‫ ܆‬Widowed ‫ ܆‬Partnered
B. ADDITIONAL INFORMATION
Copy of current (unexpired) US Government issued photo ID (i.e. driver
license, passport) attached
SA
NPI Number:
Copy of letter attached
Yes
Are you a US citizen? (If “Yes”, skip to section C)
Yes
Country of Citizenship:
Do you have the legal right to work in the United States?
Yes
No
Permanent Resident Status:
Alien Status:
Alien Number:
Branch
PL
M
Yes
No
If “No”, documentation of immigrant status attached
Yes
No
C. MILITARY SERVICE/COAST GUARD:
No
Date Enlisted/Commissioned
Discharge Type
No
Discharge Date
D. OPTIONAL INFORMATION
E
*If discharged please submit a copy of your DD214 Form with your application.
The information in this section is optional. If you choose not to respond, your application will not be
affected in any way. If you respond, the information will be used for statistical reporting to entities such
as State and Federal Government.
Race/Ethnic Origin
Gender
Male
English Only
Language 1
Yes
Female
Language 2
No
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
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INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF
E. CONTACT INFORMATION
Home Address
Street Name and Number
City
State
Home Phone
Cell Phone
ZIP
Pager
Email Address
Office Address
Street Name and Number
City
State
ZIP
Office Contact
Phone
(615) 322-3000
FAX
Are you accepting new patients?
SA
Office Email Address
Yes
Practice Coverage:
Office Hours: Monday – Friday
Saturday
No
Sunday
M
After-Hours Covered By (Partners or Group Name)
F. BOARD CERTIFICATION
PL
Emergency On-Call Number
Is this an answering service?
Yes
No
E
List all board certifications you possess and submit copies of original certificates with your application.
First Board Certification
Name of Board
Specialty
Certification Date
Certificate Number
Have you been recertified?
Yes
No
Recertification date
Have you been recertified?
Yes
No
Second Board Certification
Name of Board
Specialty
Certification Date
Certificate Number
Recertification date
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
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INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF
G. GRADUATE EDUCATION AND TRAINING
Please provide a complete chronological history beginning with your highest level of education to present.
For gaps in time greater than 30 days, a written explanation must be submitted with your
application including the name(s) and contact information of individual(s) who can verify the
information.
Graduate Training
Graduate/Professional School
Degree
Registrar/Verifying Office Name
Address
City
State
Phone
FAX
Attended From (MM/DD/YYYY):
To (MM/DD/YYYY):
SA
Additional Training 1
Graduate/Professional School
ZIP
Degree
Registrar/Verifying Office Name
State
Phone
PL
City
M
Address
ZIP
FAX
Attended From (MM/DD/YYYY):
To (MM/DD/YYYY):
E
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
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INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF
H. HOSPITAL AND OTHER INSTITUTIONAL AFFILIATIONS
List all hospital/health system affiliations where you have been employed, practiced, associated, or
privileged for the purpose of providing patient care. DO NOT list affiliations that were part of your
graduate training. Please mark your Primary Facility in the space provided.
Local Hospitals
Affiliation Dates (MM/DD/YYYY) Primary Facility
1. Centennial Medical Center
From__________ To__________
‫܆‬Yes
‫܆‬No
2. Gateway Medical Center
From__________ To__________
‫܆‬Yes
‫܆‬No
3. Jackson-Madison County General Hospital
From__________ To__________
‫܆‬Yes
‫܆‬No
4. Maury Regional Medical Center
From__________ To__________
‫܆‬Yes
‫܆‬No
5. Nashville General at Meharry
From__________ To__________
‫܆‬Yes
‫܆‬No
6. Parthenon Pavilion
From__________ To__________
‫܆‬Yes
‫܆‬No
7. St. Thomas Midtown
From__________ To__________
‫܆‬Yes
‫܆‬No
8. St. Thomas Rutherford
From__________ To__________
‫܆‬Yes
‫܆‬No
9. St. Thomas West
From__________ To__________
‫܆‬Yes
‫܆‬No
10. Skyline Medical Center
From__________ To__________
‫܆‬Yes
‫܆‬No
11. Southern Hills Medical Center
From__________ To__________
‫܆‬Yes
‫܆‬No
From__________ To__________
‫܆‬Yes
‫܆‬No
From__________ To__________
‫܆‬Yes
‫܆‬No
14. Tennessee Christian Medical Center
From__________ To__________
‫܆‬Yes
‫܆‬No
15. University Medical Center (Lebanon)
From__________ To__________
‫܆‬Yes
‫܆‬No
16. Vanderbilt University Medical Center
From__________ To__________
‫܆‬Yes
‫܆‬No
M
SA
12. Summit Medical Center
13. Sumner Regional Medical Center
17. Vanderbilt Stallworth Rehabilitation Hospital
From__________ To__________
‫܆‬Yes
‫܆‬No
18. VA Medical Center (Nashville)
From__________ To__________
‫܆‬Yes
‫܆‬No
From__________ To__________
‫܆‬Yes
‫܆‬No
From__________ To__________
‫܆‬Yes
‫܆‬No
PL
19. VA Medical Center (Murfreesboro)
20. Williamson Medical Center
E
If you have current or past affiliations with hospitals other than those listed above, please list
all of them below. Submit additional hospital affiliations with your application if necessary.
Hospital Affiliation 1
Facility Name
Med. Staff Office/Verifying Department
Affiliated From (MM/DD/YYYY):
Department
To (MM/DD/YYYY):
Is this your primary facility?
Yes No
Category
Address
City
State
Phone
Fax
ZIP
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
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Hospital Affiliation 2
Facility Name
Med. Staff Office/Verifying Department
Affiliated From (MM/DD/YYYY):
To: (MM/DD/YYYY)
Department
Is this your primary facility?
Yes No
Category
Address
City
State
Phone
FAX
ZIP
Hospital Affiliation 3
Facility Name
SA
Med. Staff Office/Verifying Department
Affiliated From (MM/DD/YYYY):
Department
Is this your primary facility?
Yes No
Category
PL
M
Address
To (MM/DD/YYYY):
City
State
Phone
ZIP
FAX
E
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
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INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF
I. WORK HISTORY
Please provide a complete chronological history beginning with your highest level of education to present.
For gaps in time greater than 30 days, a written explanation must be submitted with your
application including the name(s) and contact information of individual(s) who can verify the
information.
Work History 1
Employer Name
Title/Position
Contact Name
Address
City
State
Phone
FAX
Employed From (MM/DD/YYYY):
To (MM/DD/YYYY):
Work History 2
Employer Name
Title/Position
City
Contact Name
PL
Address
M
SA
Reason for Leaving
ZIP
State
Phone
ZIP
FAX
E
Employed From (MM/DD/YYYY):
To (MM/DD/YYYY):
Reason for Leaving
Work History 3
Employer Name
Title/Position
Contact Name
Address
City
State
ZIP
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
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Phone
FAX
Employed From (MM/DD/YYYY):
To (MM/DD/YYYY):
Reason for Leaving
Work History 4
Employer Name
Title/Position
Contact Name
Address
City
State
Phone
FAX
Employed From (MM/DD/YYYY):
To (MM/DD/YYYY):
Work History 5
Employer Name
Title/Position
City
Contact Name
PL
Address
M
SA
Reason for Leaving
ZIP
State
FAX
Employed From (MM/DD/YYYY):
E
Phone
ZIP
To (MM/DD/YYYY):
Reason for Leaving
J. PROFESSIONAL LIABILITY DISCLOSURE QUESTIONS AND INFORMATION
Professional Liability Disclosure Questions
Have any judgments or settlements ever been made against you or on your behalf in
professional liability cases?
Yes*
No
Are any professional liability claims or cases currently pending?
Yes*
No
Have you ever been denied professional liability insurance or has your policy ever been
cancelled?
Yes*
No
*If the answer to any of the additional liability questions above is “Yes”, please submit full
details with your application
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
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INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF
Professional Liability Coverage Information
Beginning with current policy, list ALL of your professional liability carriers for the past 5 years for each
facility including coverage during graduate training, as applicable.
Current Liability Carrier
Carrier Name
Address
City
State
Phone
FAX
Issue Date (MM/YYYY):
End Date (MM/YYYY):
Policy Number
ZIP
Coverage Amount each incident
Annual Aggregate Amount
Previous Liability Carrier 1
Carrier Name
City
Issue Date (MM/YYYY):
FAX
End Date (MM/YYYY):
Coverage Amount each incident
Address
City
State
Phone
FAX
Issue Date (MM/YYYY):
End Date (MM/YYYY):
Policy Number
Annual Aggregate Amount
E
Previous Liability Carrier 2
Carrier Name
ZIP
PL
Policy Number
State
M
Phone
SA
Address
Coverage Amount each incident
ZIP
Annual Aggregate Amount
Previous Liability Carrier 3
Carrier Name
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
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Address
City
State
Phone
FAX
Issue Date (MM/YYYY):
End Date (MM/YYYY):
Policy Number
ZIP
Coverage Amount each incident
Annual Aggregate Amount
K. PROFESSIONAL/PEER REFERENCES
Provide the name and complete contact information for 3 healthcare providers as references from whom
we may request specific written feedback. All references:
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Reference 1
Name
SA
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Must be comparably licensed or an independently licensed practitioners you have worked with in the
last two years
No references may be related to you in any way
Have personal knowledge of your clinical ability, ethical character, professional performance and ability
to work cooperatively with others
At least one reference must have had organizational responsibility for your performance (i.e.,
preceptor, department chair, section chief, etc.)
Title/Position
Address
City
State
Phone
FAX
ZIP
Email
E
PL
M
At what location/facility did you work with this person?
Do or did they provide direct supervision? If “Yes” please provide dates below.
Direct Observation Start Date (MM/YYYY):
End Date (MM/YYYY):
Reference 2
Name
Title/Position
Yes
No
At what location/facility did you work with this person?
Address
City
State
ZIP
Phone
FAX
Email
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
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Do or did they provide direct supervision? If “Yes” please provide dates below.
Direct Observation Start Date (MM/YYYY):
End Date (MM/YYYY):
Reference 3
Name
Title/Position
Yes
No
Yes
No
At what location/facility did you work with this person?
Address
City
State
ZIP
Phone
FAX
Email
Do or did they provide direct supervision? If “Yes” please provide dates below.
Direct Observation Start Date (MM/YYYY):
SA
L. LICENSURE
End Date (MM/YYYY):
List all State Professional Licenses (including Tennessee) you currently hold or have held (APN, RN, etc.).
If you are not currently licensed to practice in Tennessee, you must provide documentary evidence that
you have applied for a Tennessee license.
M
Failure to do so will delay the processing of your initial appointment application.
Issuing State
Licensing Authority
Expiration Date (MM/YYYY):
License 2
Name (exactly as it appears on license)
Issuing State
License Number
Licensing Authority
Issue Date (MM/YYYY):
E
Issue Date (MM/YYYY):
PL
License 1
Name (exactly as it appears on license)
License Number
Expiration Date (MM/YYYY):
License 3
Name (exactly as it appears on license)
Issuing State
Licensing Authority
Issue Date (MM/YYYY):
License Number
Expiration Date (MM/YYYY):
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
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License 4
Name (exactly as it appears on license)
Issuing State
Licensing Authority
Issue Date (MM/YYYY):
License Number
Expiration Date (MM/YYYY):
Drug Enforcement Administration (DEA) Registration for Prescribers:
Name (exactly as it appears on registration certificate)
Registration Number
Issue Date:
Expiration Date:
Please submit a copy of your DEA certification with your application.
VUMC requires a “fee paid” full schedule (2, 2N, 3, 3N, 4, and 5) DEA registration in order to
prescribe or write orders for scheduled drugs. If your DEA does not have a full schedule please
submit a full explanation with your application.
For Non-Prescribers Only:
‫܆‬Yes ‫܆‬No
I do not prescribe or write orders for scheduled drugs.
I acknowledge this is prohibited without first obtaining a full schedule DEA.
E
PL
M
SA
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
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INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF
M. DISCLOSURE INFORMATION
1. Have you, your license, or your participation with any of the entities below ever been investigated, involuntarily
denied, revoked, suspended, not renewed, placed under probation, reprimanded, subjected to an adverse action
or disciplinary action or otherwise limited or curtailed or have you voluntarily relinquished any of the items below
in anticipation of disciplinary action or any of the previously listed actions occurring or are any of these actions
pending?
a.
b.
c.
d.
e.
State Medical or other Professional License (including any out of state Professional License)?
DEA Registration or other applicable controlled substance registration?
Hospital or healthcare facility staff membership or privileges?
Medicare, Medicaid or other local, state, and/or federal government program participation?
HMO, PPO or other health plan participation?
‫܆‬Yes*
‫܆‬Yes*
‫܆‬Yes*
‫܆‬Yes*
‫܆‬Yes*
‫܆‬No
‫܆‬No
‫܆‬No
‫܆‬No
‫܆‬No
2. Has your standing with any of the following bodies been investigated, denied, revoked, suspended, reprimanded,
limited, curtailed, not renewed, placed under probation, subjected to adverse or disciplinary action or is any such
action pending?
a.
b.
c.
d.
e.
Professional ethics committee?
Regulatory Agency (CLIA, OSHA, etc.)?
Professional Malpractice Insurance Company?
Professional Training School or Program?
If others, please specify. _________________________________
‫ ܆‬N/A
‫܆‬Yes*
‫܆‬Yes*
‫܆‬Yes*
‫܆‬Yes*
‫܆‬Yes*
‫܆‬No
‫܆‬No
‫܆‬No
‫܆‬No
‫܆‬No
SA
3. Have you ever been under investigation for, convicted of, arrested for, charged with, or pled to, any crime (other
than minor traffic violations), including crimes involving child abuse/molestation?
‫܆‬Yes* ‫܆‬No
4. In addition to #3 above, have you ever been investigated for or found to be a perpetrator of child abuse, child sex
abuse, or neglect by ANY local, state or federal agency, such as Child Protective Services?
‫܆‬Yes* ‫܆‬No
M
5. Have you been denied certification/recertification or been subject to any disciplinary action, (excluding action
associated with lack of meeting attendance or non-payment of fees?)
‫܆‬Yes* ‫܆‬No
‫܆‬Yes*
‫܆‬No
7. Have you ever opted out of Medicare?
‫܆‬Yes*
‫܆‬No
PL
6. Have you ever been sanctioned by any other federal or state agency other than those
specified above, including TennCare or Worker’s Compensation Board?
E
8. Have you ever been denied membership, renewal thereof, or been subject to any disciplinary action (excluding
action associated with lack of attendance or non-payment of fees) in any healthcare organization or professional
society, licensing or certifying board, whether federal, local, or state, or have proceedings by any of these been
instituted?
‫܆‬Yes* ‫܆‬No
*If the answer to any of the Disclosure Information questions above is “Yes”, please submit
full details with your application.
N. ABILITY TO PRACTICE MEDICINE
1. Are you able to safely perform all of the essential functions related to the specific clinical privileges you are
requesting with or without reasonable accommodations?
‫܆‬Yes ‫܆‬No*
*If “NO”, please submit full details with your application.
2. Do you currently or have you in the past engaged in the unlawful use of drugs, including the use of prescription
drugs, not under the supervision of a licensed health care professional other than yourself?
‫܆‬Yes* ‫܆‬No
*If “Yes”, please submit full details with your application.
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
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APPLICATION APPROVAL CONDITIONS: In making application for membership, I acknowledge that I will abide by
the bylaws of the hospital(s), participating organization(s) and the medical ethics of the applicable licensing boards of
Tennessee. I agree to be bound by the terms thereof if I am granted membership. As a condition of re-appointment, I
agree that I will not participate in any form of fee splitting. I agree to abide by the medical staff bylaws and rules and
regulations of the hospitals, clinics and institutions or other organizations to which I have applied for membership or
requested professional staff privileges. I agree to abide by the patient bill of rights for those institutions for which I
requested consideration.
I understand and agree that, as an applicant to the participating organizations and as an applicant for professional
staff membership, I 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 believe that I am qualified to perform all procedures for which I have requested privileges. I have not requested
privileges for any procedure for which I am not qualified.
SA
I pledge to maintain an ethical practice, to provide for continuous care for my patients, and to refrain from delegating
the responsibility for any aspect of the care of my patients to any practitioner not qualified to undertake that
responsibility. I pledge to participate in the educational activities provided by the facility, to abide by the bylaws, rules
and regulations of the Medical Staff and the Governing Boards, to accept committee assignments as appropriate, to be
subject to review as part of the quality assessment program, and agree that neither the facility to which I am applying
or any member of the medical staff will be liable for any communication made during the credentialing process. I will
avoid unwarranted publicity, dishonesty in any financial commercialism and to refuse acceptance in money, goods, in
kind- or any inducement whatsoever from consultants, practitioners, makers of surgical appliances, instruments, and
pharmaceuticals or others, and to make my fees commensurate with the service rendered and with the patient’s
rights, and to avoid discrediting my associates by taking unwarranted compensation. I further pledge to comply with
all ethical standards in the Code of Conduct.
PL
M
ACKNOWLEDGEMENT AND SIGNATURE
I attest that the information provided in or attached to this application is accurate and complete. I understand that a
condition of this application is that any misrepresentation, misstatement, or omission from the application, whether
intentional or not, may be cause for automatic and immediate rejection of this application and may result in the denial
of membership and privileges and/or termination of any contract with any institution upon subsequent discovery of
such misrepresentations, misstatements or omissions, and the hospital(s) or any other participation organization may
immediately terminate my appointment, privileges, and/or membership. By my signature below, I further
acknowledge and agree that I will promptly and fully report all information to the Credentials Committee(s) of each
institution to which I am applying should any of the following occur: (1) any of the answers in the application change,
(2) any situation arises which affects my ability to treat patients at any time after I have signed and dated this form,
while my application is pending, or if I am appointed to the Medical Staff, Network or Foundation while I maintain
membership.
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I agree that my completed application and information submitted with it to VUMC may be shared with
Vanderbilt Health Affiliated Network
Yes
No
Please indicate the Vanderbilt facilities at which you practice:
VANDERBILT UNIVERSITY MEDICAL CENTER
Vanderbilt Hospital & Clinic
Vanderbilt Psychiatric Hospital
Monroe Carell Jr. Children’s Hospital at Vanderbilt
Printed Name: ________________________________________________
Original Signature:
__________________________________________
Date: ______________________
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
07/09/2015
VUMC INIT PROF 20150218
15 of 18
INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF
INVESTIGATION CONSENT AND AUTHORIZATION: By applying for appointment to the professional staff of
a hospital, for membership or participation in any other organization to which I am applying, I hereby
signify my willingness to appear for interviews with regard to my application, and I authorize
representatives of the hospital, clinical staff, representatives of the institutions or other organizations to
consult with administrators and members of the medical staffs of other hospitals, medical associations,
institutions, state medical boards or professional licensing authorities with which I have been associated. I
further authorize a criminal background check and contact with other entities to obtain information,
including but not limited to coverage and claims information from past and present malpractice insurance
carriers who may have information bearing on my professional competence, character and ethical
qualifications.
I hereby further consent to the release and inspection of all records and documents by and to any or all of
the following: representatives of clinical staff, representatives of the institutions, the hospital, its medical
staff, clinical staff, representatives of the institutions, third party payers, accrediting bodies and their
authorized managed care designee. These records may include malpractice claims history, medical staff
credentials files and any other pertinent records (including those at other hospitals with which I am
affiliated) that may be material to an evaluation of my professional qualifications, clinical privileges
requested, competency for enrollment into managed care health plans, ability to carry out my professional
practice, as well as moral and ethical qualifications for membership and appointment to the professional
staff of a hospital or clinic.
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I present this information as part of this credentialing process in the expectation that its confidentiality
and privacy will be preserved, and this information will be released or disclosed only as part of current and
future credentialing, peer review and quality assurance processes, to the extent possible under State and
Federal law.
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WAIVER OF LIABILITY: I hereby release from liability all representatives of a Centralized Credentials
Verification Service, Vanderbilt University, its trustees, employees and officers, participating organizations,
the hospital, clinical staff and representatives of the institution for their acts performed in good faith and
without malice in connection with evaluating my application and my credentials and qualifications. I
hereby release from liability any and all individuals and organizations who provide information to a
hospital or its medical staff, clinical staff, representatives of the institutions and participating
organizations, Vanderbilt University or the Centralized Credentials Verification, in good faith and without
malice, concerning my professional competence, ethics, character and other qualifications for medical
association, membership or participation in designated organizations for staff appointment and clinical
privileges, and I hereby consent to release of such information.
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INFORMATION RELEASE: I hereby further authorize and consent to the release of information and
documents by the releasing institution(s) to other health care institutions, a Centralized Credentials
Verification Service, or providers as long as such release of information is done in good faith and without
malice. I hereby release from liability the releasing institution(s), its trustees, its employees, agents,
officers, servants, faculty and staff in connection with sum provision of information.
APPLICATION PHOTOCOPY APPROVAL: By applying to any hospital or organization for privileges, I
authorize the institution(s) checked in the previous section to provide any other hospital(s), managed care
organization(s) or other organizations a copy of this application and agree that a photocopy of this
application or a fax copy of this application and release shall be as sufficient as though I had duly
executed the same in my own handwriting.
Printed Name: ______________________________________
Original Signature____________________________________
Date: ______________________
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
07/09/2015
VUMC INIT PROF 20150218
16 of 18
INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF
APPOINTMENT/PROTOCOL APPROVAL FORM
Advanced Practice Registered Nurse/Physician Assistant
APPOINTMENT/PROTOCOL APPROVAL FORM
The accompanying signatures serve to recommend the appointment of ___________________________
as ______________________________ in the Department of __________________________________
for a period not to exceed two years commencing ______________________.
Practice location:
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If applicable, (APRN/ PA) the accompanying signatures serve to confirm the attached list of evidenced
based practice protocols/guidelines have been reviewed and approved by both the practitioner and
supervising physician and are consistent with the practitioner’s scope of practice/delineation of privileges
and specific to the patient population. [http://tennessee.gov/sos/rules/0880/0880-06.pdf]
Protocol review and revision will occur every two years consistent with the reappointment process.
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SUPERVISING PHYSICIAN(S)
1.
2.
(Name/Title)
(Date)
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(Signature)
(Name/Title)
(Signature)
(Date)
(Signature)
(Date)
(Signature)
(Date)
APRN/PA Applicant:
(Name/Title)
Chief of Service/Division:
(Name/ Department)
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
07/09/2015
VUMC INIT PROF 20150218
17 of 18
INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF
PROVIDER ACKNOWLEDGEMENT STATEMENT
Dear Provider:
In accordance with Regulation 42 CR 412.46, HCFA requires that Vanderbilt obtain a Provider
Acknowledgement Statement at the time of appointment. When signed, the statement is an
acknowledgement that you are aware of Medicare regulations pertaining to physician attestation for
hospital billings to Medicare. Please sign the statement below and return it to Provider Support Services
with your application. These federal regulations require that the statement be part of your file prior to
patient contact.
Thank you for your cooperation.
C. Wright Pinson, MBA, MD
Deputy Vice Chancellor for Health Affairs
CEO of the Hospitals and Clinics
Vanderbilt University Medical Center
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_____________________________________
Provider’s Name (Please print or type)
Provider NPI No. (MUST be included)
______________________________________
Signature
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______________________________________
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Notice to Physicians: Medicare payment to hospitals is based in part on each patient's principal and
secondary diagnoses and the major procedures performed on the patient, as attested to by the patient's
attending physician by virtue of his or her signature in the medical record. Anyone who misrepresents,
falsifies, or conceals essential information required for payment of Federal funds, may be subject to fine,
imprisonment, or civil penalty under applicable Federal laws.
_____________________________________
Date
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
07/09/2015
VUMC INIT PROF 20150218
18 of 18
ELEMENTS OF INFORMED CONSENT
1.
The nature of the patient’s condition;
2.
The proposed surgical, medical or radiological procedure and the operative site (if applicable)
3.
The benefits and risks of the proposed procedure(s) stating the frequently occurring and significant risks,
using the phrase, “including but not limited to: and state, “it is not possible to guarantee results”;
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4.
Explain treatment alternatives, including no treatment;
5.
The consequences of no treatment;
6.
Who will be performing the procedure and a description of the role of residents or others who may
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perform significant portions of the procedure;
The risks of anesthesia;
8.
Potential blood/blood product transfusions
9.
The patient or patient’s legal representative should be given the opportunity to ask questions and receive
additional information as requested;
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7.
10. The patient must be able to “teach back”: Describe in his/her own words the procedure, the risks and
benefits, and what parts of his/her body will be involved;
Vanderbilt Medical Group
Designation of Agent
For Preparation and Submission of Forms, Applications and Check Authorization
I
, hereby authorize the Director of the
Vanderbilt Medical Group Business Office (or his/her duly appointed designee):
1. To act as a proxy agent for me in the preparation, signature when required, and submission of
applications, authorization agreements and insurance forms. This proxy status is inclusive of
creating a user account and logging into internet-based systems of the Centers for Medicare and
Medicaid Services (CMS) – Identity and Access Management (I&A) System, National Plan and
Provider Enumeration System (NPPES), and Provider Enrollment, Chain and Ownership System
(PECOS).
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2. To complete CMS Meaningful Use Attestation when qualified as an Eligible Professional, and
when appropriate certified EHR objectives and measures are met. I also consent to reporting of
provider and practice level data for designated clinical quality measures as part of the CMS
Physician Quality Reporting System (PQRS).
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3. To release my signature electronically or by facsimile on all documents and applications
necessary for my enrollment into managed care health plans, with which VMG has a provider
contract. I understand that release of my signature in this way shall be as sufficient as though I
had duly executed the same in my own handwriting.
I am given the following assurances by the Director of the Vanderbilt Medical Group Business
Office (or his/her duly appointed designee):
a.
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b.
Insurance claim forms will be prepared only in those instances where I have submitted an
appropriately documented charge as supported in the medical record.
That all insurance proceeds made payable to me will be entered in my revenue accounts.
4. Through the Payments Section of the Vanderbilt Medical Group to restrictively endorse and
deposit to an Account of Vanderbilt University all checks made payable to me received as
payment of fees for professional services rendered by me to or on behalf of my patients pursuant
to provisions of the Vanderbilt Medical Group Bylaws. This authority will continue until the
same is revoked in writing.
Signature Approval
Date
VANDERBILT MEDICAL GROUP
PARTICIPATION AGREEMENT
WHEREAS, the undersigned Participating Member desires to engage in the group
practice of rendering professional services in the care of patients as a member of the Vanderbilt
Medical Group (VMG), and VMG desires that Participating Member engage in professional
practice as a member of the VMG;
NOW, THEREFORE, in consideration of Participating Member’s employment by Vanderbilt
University and participation in the VMG, it is agreed as follows:
Agreed to and Accepted by:
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1. Bylaws. Participating Member agrees that he/she has received, read and will abide by the
Bylaws of the VMG, which bylaws are hereby incorporated by reference and made a part
of this Participation Agreement.
2. Group Practice. Participating Member shall not engage in any professional activities in
the care of patients except in accordance with the standards and conditions set forth in the
Bylaws of the VMG and/or as established by the Board of Directors of the VMG.
3. Fees. Reimbursement and fees for all of the professional patient care services rendered by
Participating Member shall be endorsed over to and shall be the property of Vanderbilt
University.
4. Health Plan Contracts. Participating Member shall enroll in any and all health insurance
plans as participating member of the VMG, and may not contract with, or opt out of, any
health insurance plan, including but not limited to the Medicare program, except as a
member of and together with the VMG.
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Participating Member
VANDERBILT UNIVERSITY by
and through its SCHOOL OF
MEDICINE
______________________________
(Signature)
By:
___________________________
______________________________
(Printed Name)
______________________________
Title: _________________________
(Department Chairman Signature)
______________________________
(Printed Name)
______________________________
Department
______________________________
(Printed Name)
Date: _________________________
PROFESSIONAL LIABILITY APPLICATION
1. Name of Physician
3. Effective Date
4. SSN or Employee ID #
5. Department
2. Degree
Code - For Risk Management Use Only
6. Division
7. Specialty
8. Physician Status: Fellow ________ Faculty ________ Fellow with Faculty Appointment ________
9. Full Time: ________ Part Time: ________ Clinical Hours Per Week ________
* Clinical hours must include time devoted to inpatient rotations, scheduled clinics, participation on consult service, supervision of fellows & residents in their care
and clinical responsibilities and must include on call time, including nights, weekends, and holidays.
10. Please circle time to Veterans Administration (VA):
0
1/8
2/8
3/8
4/8
5/8
6/8
7/8
8/8
11. Check all that apply.
Surgical Specialties
Bariatric Surgery
80225
Orthodontics/Dentistry
80474
Pediatric Surgery
(including other weight
reducing procedures)
80425
Ophthalmology / Surgical
Procedures
80156
Plastic Surgery
80177
Podiatry (Procedures)
80141
Cardiac Surgery
80154
Orthopedic Surgery
80132
Surgical Oncology
80115
Colon/Rectal Surgery
(other than Trauma)
80144
Thoracic Surgery
80143
General Surgery
80155
Otolaryngology/Plastics
80171
Trauma
80167
Gynecology Surgery
80170
80145
Urology
80152
Neurosurgery
Otolaryngology Head & Neck
Surgery
80153
OB Delivery
80159
Oral Surgery
80140
80254
Allergy
80151
Anesthesiology
Otolaryngology (all types OTHER
80106
Vascular Surgery
Other (please explain)
than major Head & Neck Surgery &
Plastics)
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Other Specialties
80146
80222
Medicine or Pediatric Specialty - No Procedures (Diabetes, Endocrinology, Hematology/Oncology,
Infectious Disease, Rheumatology, Gastroenterology, Nephrology, Child Development, etc)
Cardiology / No Procedures
80471
Neonatology
72401
Psychology
80422
Cardiology / Procedures (see
procedure list below)
80261
Neurology
80469
Pulmonary Medicine/Critical Care
80234
Clinical Pharmacology
80466
80960
CRNA
80256
Dermatology / General
80233
80456
Dermatology / Procedures
80263
80424
ED (Fast Track Only)
80102
80248
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80255
Nutrition
Do you attend in ICU? (please circle)
OB / GYN Outpatient or Clinic
Visits Only
YES
or
NO
Radiation Oncology
Occupational Medicine
Ophthalmology (No surgery)
80491
Radiology Procedures / Interventional
71801
Optometry
80253
Radiology, Diagnostic / No Procedures
Emergency Medicine
80266
Pathology / No Procedures
71800
Research - Patient Oriented, but NO patient
80257
General Internal Medicine
80292
80267
General / Medicine Pediatric
Medicine or Pediatric Specialty Procedures (see procedure list
80235
Pathology / Procedures
Physical Medicine & Rehab /
below) - Diabetes, Endocrinology,
Hematology / Oncology, Infectious
Disease, Rheumatology,
Gastroenterology
Sports Medicine
(includes dye injections & Nuclear Medicine)
care, no resident supervision of any kind
Other (please explain)
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80446
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80429
80250
Podiatry / No Procedures
80249
Psychiatry
12. If not in Anesthesia, critical care, or a surgical discipline please review the following lists and check all that apply. If you perform or may be called upon to perform or
supervise any of these procedures at least once a year, we need to know for appropriate insurance coverage.
Please check the following medical techniques or procedures you perform:
Angiography
Arteriography
Bone Marrow Harvest
Bronchoscopy (rigid or flexible)
Catheterization-Arterial, cardiac, or diagnostic, but
does not include:
1. Occasional emergency insertion of pulmonary wedge,
pressure recording catheters.
2. Urethral Catheterization
3. Umbilical cord catheterization for diagnostic purposes or for
monitoring blood gases in newborns receiving oxygen.
Colonoscopy
Dermatology Faculty - Advanced Dermalogic Surgery
Endoscopy
ERCP (Endoscopic retrograde cholanglopancreatogarphy)
Lasers - used in therapy
Lympangiography
Mohs Surgery
Myelography
Needle Biopsy
Pneumatic or mechanical esophageal dilation
Radiopaque dye injections into blood vessels, lymphatics, sinus tracts
and fistulae
Transesophageal Echocardiography
Other ________________________________________
Budget Number to be charged: _________________________________________ (Please provide only one budget number.)
Physician/CRNA Signature & Date
Department Administration Signature & Date Verifying Completion of Form
04/03/07
PROFESSIONAL STAFF BILLING APPLICATION
Name:
Title:
Department:
Nurse Practitioner
Certified Nurse Midwife
Physician’s Assistant
PhD Psychologist
Psychological Examiner
Genetics Counselor
Licensed Therapist
Other
The following questions are to be answered by Department/Division Employing Applicant:
1.
What is the employee’s academic appointment?
SON
SOM
(Faculty appointment letter must be attached with this application)
2.
What is the home department number of the employee?
3.
Salary Responsible Entity:
4.
Department Business Officer and/or Billing Manager (Name contact for information and notification)
Hospital
Name:
SON Owned
Phone#: (615) 322-3000
Title:
Please list the funding sources of the employee’s salary [should match with PAF]:
Center #
Center #
Center Name
%
Center Name
%
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Center #
Center Name
If grant funded, explain:
%
Please indicate the following:
Site(s) of service:
Supervising Physician:
Mapped to Epic Dept #
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6.
Department/Division
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5.
Job Code?
and Center #
Responsible party for completing income distribution form (IDF)
Name:
Title:
7.
Indicate if this will be a new position or replacement position.
8.
FTE Status:
Phone#:
New
Chairman’s Signature
Billing Committee:
Replacement
Date
Approved
Rejected
Committee Chair Signature
Date
Submit Application with attached PAF and Faculty Appointment Letter to:
Office of Advanced Practice
Vanderbilt University Medical Center
Suite S-2406
Medical Center North
Nashville, TN 37232-2183
For questions call 343-5356 or 322-4664
(May fax copy for initial review to 322-3490,
must have original on file for approval)
Provider Support Services
4163 Village at Vanderbilt
NASHVILLE, TN 37232
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DO NOT DUPLICATE
BLUECROSS BLUESHIELD OF TENNESSEE, Inc. (BCBST)
PRACTITIONER PRE - APPLICATION
(Includes MDs, Physician Extenders and Health Care Practitioners)
Completion and acceptance of this Pre-Application by BlueCross BlueShield of Tennessee, Inc. is not a guarantee of Network Participation.
Appeals related to this Pre-Application will be governed by BlueCross BlueShield of Tennessee, Inc. policies and procedures.
Pre-Application must be completed in its entirety, including the Professional History section. Please complete carefully and legibly.
Name ________________________________________________, ________________________________________________, _________, ________________
Last
First
Mid. Int.
Degree
Vanderbilt Medical Group
Group Practice Name: _______________________________________________________________________________________________________________
3601 The Vanderbilt Clinic
(615) 322-3000
Primary Office Location: ____________________________________________________________________________
Phone # (______)___________________
(Please list all other locations, City, State, Zip and County on a separate sheet of paper and attach to pre-application.)
Davidson
Nashville
TN
37232-5100 County (TN or Contiguous) _____________________________________
City: _________________________________________
State: _______________
Zip: ____________
Social Security Number: _________________________ Date of Birth:____________________ Gender: M or F Primary Specialty: _______________________
TN
Secondary Specialty: ______________________ Licensure Number: ______________ State Issuing License: ______
DEA Certification Number: ____________
APN Licensure Number (CRNAs, NMWs, NPs): ____________________________ RN Licensure Number (CRNAa, NMWs, NPs): _______________________
Name of Medical/Professional School(s) attended: ____________________________________________________________ Date of Graduation: _____/____/___
MM / DD / YY
Address: ____________________________________________________________________________________________________________________________
Marian R. Gardner, Manager Payer Enrollment
Office Contact Name and Title ___________________________________________________________________________________________________________
CHECK NETWORKS APPLYING FOR:
✔
_____
Blue Network C
✔
✔
✔
_____
Blue Network P
_____
Blue Network S _____Blue
Network K
✔
_____
TennCareSM Select _____ BPN
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✔ BlueCare®
____
Provider Responsibilities
1)
2)
✔ Yes ___ No
Do you have malpractice insurance coverage for a minimum of at least $1,000,000.00 per claim and $3,000,000.00 in the aggregate? ___
a) If the answer is No, do you only work for the State of Tennessee? ______
✔
Do
you
have
admitting
privileges
with
a
BCBST
network
hospital?
________
If
Yes,
at
which
hospital(s)
Vanderbilt University Hospital
___________________________________________________
a) If No, please list BCBST practitioner providing your provision for coverage and BCBST hospitals where he/she has admitting privileges ________________________
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b) If you are a nurse practitioner, physician assistant or certified nurse midwife, please enter your preceptors’ name and BCBST network hospital where he/she admits:
_______________________________________________________________________________________________________________________________________________
Professional History
No
( )
( )
( )
4.
( )
( )
5.
( )
( )
6.
( )
Yes
( ) Are you currently practicing with an invalid or expired license?
( ) Is your license to practice restricted?
( ) a. Has your medical license been revoked or not renewed (a license "revocation") by any jurisdiction within the last two (2) years, for cause, or
have you surrendered your license to avoid such a revocation?
b. If answer to 3.a. is yes, please indicate date license was re-issued. ______________________
( ) c. Do you have a license revocation action pending or initiated against you?
( ) a. Has your Drug Enforcement Administration Certificate(DEA) or Controlled Dangerous Substances Certificate(CDS) been revoked, or not renewed
(a "revocation") by any jurisdiction within the last two (2) years, for cause, or surrendered to avoid imposition of such revocation?
b. If yes, please indicate date(s) DEA and/or CDS certificates was/were re-issued. DEA _____________ CDS _______________
( ) c. Do you have DEA or CDS certificate revocation actions pending or initiated against you?
( ) Have you been convicted of fraud, felony, or any offense involving moral turpitude by any jurisdiction within the last two (2) years, or is such action
pending or been initiated against you?
( ) Are you currently sanctioned by Medicare or Medicaid? (e.g. excluded from participation in Medicare or Medicaid Program(s))
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1.
2.
3.
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Please read the following questions carefully.
CERTIFICATION OF PROFESSIONAL HISTORY and PROVIDER RESPONSIBILITIES
As a condition of my participation in any BCBST product network, I agree to maintain general liability insurance coverage with reasonable limits and worker’s compensation insurance
coverage in accordance with applicable state law. Further, I agree to maintain such coverage continuously while participating in any BCBST product network, and will provide acceptable
proof of such coverage to BCBST upon request.
I, the undersigned practitioner, certify that the above and any additional information provided is complete, accurate, and true. I acknowledge that falsification, inaccuracy, or failure to fully
disclose any information requested is grounds for rejection of practitioner’s application for any BCBST Provider Networks. I hereby authorize BCBST to query the National Practitioner
Data Bank (NPDB) and the Healthcare Integrity and Protection Data Bank (HIPDB) and further release BCBST from any and all liability arising from querying and reporting to the HIPDB
as required by 45 CFR Part 61, except to the extent BCBST has actual knowledge of the falsity of the reported information. I further agree that any dispute relating to or arising in
connection with this application must be resolved in accordance with applicable BCBST policies and procedures.
Date: ______________________________ Signature: ____________________________________________________________________________________________________
Please print name of Provider Relations Representative submitting Pre-Application: _____________________________________ Date: ____ _________
For BCBST Use Only:
PreApp Rev 13 12/15/04
IMPORTANT NOTICE REGARDING IMMUNIZATIONS
EFFECTIVE IMMEDIATELY, ALL VANDERBILT EMPLOYED
PRACTITIONERS WILL BE REQUIRED TO BE COMPLIANT WITH
VANDERBILT MEDICAL CENTER IMMUNIZATIONS PROGRAM
AND TUBERCULIN (TB) SKIN TESTING AT THE TIME OF THEIR
INITIAL APPOINTMENT OR REAPPOINTMENT.
Faculty:
You can check your record of compliance on the Faculty
Orientation and Training Office website at
http://www.mc.vanderbilt.edu/medschool/FOTO/.
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Staff:
Your supervisor can check your compliance status on MyVandy
by viewing the “Record of Compliance in Occupational Health”
report.
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Email any additional questions to
[email protected]
If you prefer to contact Occupational Health by phone, please
call 6-0955
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Pre-Arrival Immunization and Screening Form for Newly Credentialed Faculty
Please return completed form and documentation by fax to:
Vanderbilt Occupational Health Clinic
Fax # (615) 936-0966 Phone # (615) 936-0955
The Occupational Health Clinic would like to welcome you to Vanderbilt. Our clinic is dedicated to
protecting you and your patients from infectious diseases. To meet the requirements of the Medical
Center Policies and OSHA, you will need documentation for the following immunizations and/or tests
before beginning work at Vanderbilt.
This worksheet should be completed and documentation of all immunizations and tests must be
attached. For explanation of requirements, see reverse side.
Name: __________________________________ SS#: ________-______-_________
Date of Birth: _________________
Department:__________________
Anticipated Start Date: ___________________
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TUBERCULOSIS: Two TB skin tests are required within 12 months prior to your start date at Vanderbilt.
One of these must be within 3 months of the start date:
Date #1: ____/____/____ Result
ˆ (+)
ˆ (-)
Date #2: ____/____/____ Result
ˆ (+)
ˆ (-)
If you have a previous positive skin test (>10mm indurations) or a positive IGRA (e.g
QuantiFERON or T-spot):
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Date of first positive TB skin test: ____/____/____
Dates of INH therapy, if taken: ______________________
Attach the official report of a chest x-ray taken within the past 6 months.
DISEASES
IMMUNIZATION
DATES
(For detailed immunization
requirements, see reverse side)
MMR
Measles
Date
Result
ˆ(+)
ˆ(-)
(2)
ˆ(+)
ˆ(-)
(1)
(2)
ˆ(+)
ˆ(-)
(1)
(2)
ˆ(+)
ˆ(-)
(1)
(2)
(1)
(3)
Document any additional
hepatitis B shots here:
Varicella/chickenpox
(remember to attach
documentation)
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Hepatitis B
(remember to attach documentation)
Antibody Tests
(Rubeola or red measles)
Mumps
(1)
ˆ(+)
ˆ(-)
Rubella
(1)
ˆ(+)
ˆ(-)
(German measles)
Tetanus/Diphtheria (optional)
Last booster:
Tetanus/Diphtheria/Pertussis (optional)
Date:
Ƒ I have worked at Vanderbilt Medical Center previously – please review my employee
immunization records.
Ƒ I have received immunizations as a patient or student at Vanderbilt and give Occupational
Health my permission to review my medical record for them. Signature required:
_____________________
VUMC IMMUNIZATION/SCREENING REQUIREMENTS
HEPATITIS B: If you have the potential to come in contact with human blood or
body fluids as part of your employment here, you must document either
A. A completed series of 3 hepatitis B vaccines, or
B. A hepatitis B vaccine series in progress, or
C. Laboratory evidence of immunity to hepatitis B, or
D. Informed refusal of the vaccine (by signing declination form at the Vanderbilt
Occupational Health Clinic.)
VARICELLA (chickenpox): Written documentation of a varicella immunity test drawn
from a reputable laboratory (date and result), or documentation of two doses of varicella
vaccine.
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MMR
Measles (rubeola): If born on or after 1/1/1957, written documentation of either
A. Two (2) live measles (rubeola) vaccines given at least one month apart, after
the first birthday, or
B. One (1) measles/mumps/rubella (MMR) vaccine since age 18, or
C. Laboratory evidence of immunity to rubeola (date and result,) or
D. Documentation of physician-diagnosed rubeola infection.
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Mumps: If born on or after 1/1/1957, written documentation of either
A. One dose of live mumps after the first birthday, or
B. Laboratory evidence of immunity to mumps (date and result,) or
C. Documentation of physician-diagnosed mumps infection.
E
Rubella (German measles): (Regardless of birthdate)
A. Written documentation or laboratory evidence of immunity to rubella, with
date and result, or
B.
Documentation of an MMR vaccine or a rubella vaccine after the first
birthday
TETANUS/DIPHTHERIA/PERTUSSIS: Documentation of a tetanus/diphtheria booster
within past 10 years. Td now has acellular pertussis component which is recommended
for healthcare workers and anyone who has close contact with an infant. (Optional)
TUBERCULOSIS:
A. Written documentation of either 2 negative TB skin tests within the past 12
months with the most recent being within the past 3 months, or
B. If you have a prior positive skin test (or positive quantiferon test,) you must
have a chest x-ray within 6 months prior to beginning work at Vanderbilt.
NOTE: If you have had BCG vaccine you are still required to undergo TB skin testing, unless
you have also had a previous positive skin test or quantiferon test.
STATE OF TENNESSEE
DEPARTMENT OF HEALTH
HEALTH RELATED BOARDS
TENNESSEE BOARD OF NURSING
665 MAINSTREAM DRIVE
NASHVILLE, TENNESSEE 37243
(800) 778-4123, ext. 5325166 or (615) 532-5166
ADVANCED PRACTICE NURSE
NOTICE AND FORMULARY
Advanced Practice Nurse Name _______________________________
*Advanced Practice Nurse DEA Number ___________________
TN Advanced Practice Nurse License Number_________
TN or Multistate Registered Nurse License Number_________
Delete Supervising Physician(s):______________________________Delete Practice/Clinic(s):___________________________
(If more space is needed for deletions please attach additional sheets)
SA
Check the category of legend drugs the APN is authorized to prescribe: (*must have own DEA number to prescribe Schedule’s II-V)
Non controlled legend drugs
M
Controlled legend drugs including:
_____ Schedule II
_____ Schedule III
_____ Schedule IV
_____ Schedule V
Initial or adding a new practice site(s) & Supervising Physician(s):
Site Address
____________________________________
Name of Practice/Clinic
PL
______________________________________
Name of Practice/Clinic
Site Address
E
Supervising Physician Printed Name
Supervising Physician Printed Name
Supervising Physician Signature
Supervising Physician Signature
DEA Number
DEA Number
MD/DO License Number
MD/DO License Number
Attestation
I, ___________________________________________ attest that the information contained in this application is true and correct.
Print Name
Return original to: Tennessee Board of Nursing
665 Mainstream Drive
Nashville, TN 37243
___________________________________
Signature of Advanced Practice Nurse/Date
NOTE: Mandatory Practitioner Profile will be updated based on receipt of this Notice & Formulary
PH #3625 (REV. 9/14)
This page may be duplicated
RDA #10137
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