Dear:
5($332,170(17$33/,&$7,21)25352)(66,21$/67$))
Date:
It is time for you to apply for reappointment to the Professional Staff of Vanderbilt University Medical
Center (VUMC). This application has been pre-populated with the information that we currently have on file. Please review this information and make any necessary corrections and additions to bring your record up to date. All members of the Professional Staff, who are required by state statute to work in collaboration with a physician/dentist, must additionally complete and sign the enclosed
Appointment/Protocol Approval Form at the time of reappointment.
If you DO NOT wish to renew your Professional Staff membership and/or privileges (as applicable) at VUMC please check the box below and return this cover letter in lieu of your application packet.
I do not wish to renew my Professional Staff membership and/or privileges (as applicable) at Vanderbilt University Medical Center.
SAMPLE
There is a $200 fee for processing your application. However, if your completed application is received in Provider Support Services on or before the Due Date the fee will be waived. Any application received after the due date must include a $200 payment to begin processing.
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 and/or privileges (as applicable) does not automatically grant you
Professional Staff membership and/or privileges. All applications must proceed through a verification and review process and must also be approved by the governing body.
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. If we can further assist you in this process, please contact Provider Support Services at (615) 322-3573.
Sincerely,
Provider Support Services
Ship USPS, FedEx, or UPS to:
Provider Support Services
1500 21 st Avenue South, Room 4163
Scan and email your application to PSS securely via Accellion : provider.support.services@vanderbilt.edu
Nashville, TN 37212
FAX to: 615-343-8711
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
VUMC REAP PROF 20150326
03/24/2015
1 of 16

5($332,170(17$33/,&$7,21)25352)(66,21$/67$))
Background Check Process for Persons Who Are Applying or Reapplying for
Medical/Professional Staff Membership and/or Clinical Privileges at Vanderbilt University Medical Center
Pursuant to Vanderbilt University policy, all persons who have accepted an offer of employment to be hired by Vanderbilt University must undergo a pre-employment background check. Similarly, all initial and/or reappointment applicants for medical/professional staff membership and/or clinical privileges to provide patient care services (whether employed by Vanderbilt or not) must undergo a background check, if one was not completed related to the hiring process. This background check is done via a secure website where you will submit your name, social security number, and any information on criminal convictions. In the event that the background check returns no finding of potential concern, you and the
Department Chair or Senior Associate Dean of the primary department/school will be notified by email of this result, usually within five business days of your submitting the required information. In the event of
SAMPLE a limited number of individuals from Vanderbilt senior administration would see any such information and be authorized to consider it in making recommendations about your eligibility for employment, medical/professional staff membership, and/or credentialing.
Please submit your background check information by using the link below. This link works best with
Windows compatible computers (PC) running Internet Explorer 8. Those using other internet browsers may experience difficulty accessing the application since it runs JAVA script. https://v3.vpassure.com/pub/schoolcheck_selectschool.html.vanderbilt
Enter the Company Code: 88777
When you get to the box regarding criminal record, you will indicate Y (yes) or N (no). If you have ever been convicted of, or plead guilty or no contest to a felony or misdemeanor crime, or have had any misdemeanor conviction for which you received probation with dismissal of the case by the court, you must indicate a Y (yes) response. Events such as DUI, possession of illicit substances, and even citations for open containers apply here and require a Y (yes) response. It is important that you be honest in your response.
You will be asked by the web-based application to sign electronically a release. To do so, click on the PDF release form icon at the top left on the web page and read the release. Click inside the signature box and electronically sign your name. You may then print a copy of your signed release form for your records.
If you need to exit the system, your information will be saved until you return to complete the form. Upon completing the online form, you will be asked to submit it for processing. Please note that background checks may take at least five (5) business days to process. If additional information is required to complete your background investigation, you will be contacted. For technical questions, please contact the Vanderbilt Background Check Office in Human Resources, Aimee Sadler at pebc@vanderbilt.edu
. For general questions, applicants for professional/medical staff membership and/or clinical privileges may contact the Chair/Senior Associate Dean of the primary department/school.
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
VUMC REAP PROF 20150326
03/24/2015
2 of 16

5($332,170(17$33/,&$7,21)25352)(66,21$/67$))
5(48,5(''2&80(176&+(&./,67
The following documents are required for all providers 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.
Completed Delineation of Privileges (DOP) Form (as applicable)
Complete mailing addresses in all sections
Copies of any additional Advanced Training Certifications earned during the last 2 years
Complete, signed and dated Appointment Protocol Signature Sheet (enclosed)
Copy of current Curriculum Vitae outlining education and practice history o
All date entries must be complete and include “From/To” in the format requested. o
Gaps in time greater than 30 days require a written explanation
Copy of unexpired resuscitation certification (ACLS, BLS,) as applicable
Copy of current malpractice/professional liability insurance certificate.
Copy of current Federal DEA Registration Certificate (as applicable)
SAMPLE credentialing and privileging)
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.
Professional Society Memberships (See Section I)
Professional Liability/Malpractice (See Section K)
Disclosure Information (See Section N)
Ability to Practice (See Section O)
All sections of the Reappointment 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.
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
VUMC REAP PROF 20150326
03/24/2015
3 of 16

5($332,170(17$33/,&$7,21)25352)(66,21$/67$))
$33/,&$7,21)255($332,170(17727+(352)(66,21$/67$))
Name should be listed as it appears on your license
First Name Middle Name Last Name
Social Security Number Date of Birth Degree
Suffix
Other Names by which you have been known
Maiden Former Other
Marital Status Spouse/Partner Name
܆ Single ܆ Married ܆ Divorced ܆ Widowed ܆ Partnered
Are you a US citizen? If “Yes” skip to section C
Country of Citizenship:
Alien Status:
Yes No
If “No” documentation of immigrant status attached
SAMPLE
Alien Number:
Yes No
Branch Date Enlisted/Commissioned Discharge Type Discharge Date
*If discharged please submit a copy of your DD214 Form with your application.
The information in section D 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 Female
English Language Only
Yes No
Other Language 1 Other Language 2
Home Address
State ZIP City
Home Phone
Email Address
Cell Phone Pager
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
VUMC REAP PROF 20150326
03/24/2015
4 of 16

5($332,170(17$33/,&$7,21)25352)(66,21$/67$))
Office Address
Street Name and Number
City
Office Contact
Are you accepting new patients?
Office Email Address
State
Phone
Yes No
ZIP
FAX
Practice Coverage
Office Hours: Monday – Friday Saturday
After-Hours Covered By (Partners or Group Name)
Emergency On-Call Number
SAMPLE
Sunday
Yes No
List all board certifications you possess and submit copies of original certificates with your application.
First Board Certification
Name of Board Specialty
Certification Date
Second Board Certification
Name of Board
Certificate Number Have you been recertified?
Yes No
Recertification date
Specialty
Certification Date Certificate Number Have you been recertified?
Yes No
Recertification date
Please provide a complete list of education and training completed since your last appointment at VUMC.
Education/Training 1
Graduate/Professional School Degree
Registrar/Verifying Office Name
Address
City
Phone
Attended From (MM/DD/YYYY):
State
FAX
To (MM/DD/YYYY):
ZIP
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
VUMC REAP PROF 20150326
03/24/2015
5 of 16

5($332,170(17$33/,&$7,21)25352)(66,21$/67$))
List all hospital/health system affiliations where you have been employed, practiced, associated, or privileged for the purpose of providing patient care within the last 2 years. DO NOT list VUMC hospitals or affiliations that were part of your graduate training. Please mark your Primary Facility in the space
provided
1. Centennial Medical Center From__________ To__________ ܆ Yes ܆ No
Center ܆ Yes ܆ No
3. Jackson-Madison County General Hospital From__________ To__________ ܆ Yes ܆ No
4. Maury Regional Medical Center
5. Nashville General at Meharry
From__________ To__________
From__________ To__________
܆
܆
Yes
Yes
܆
܆
No
No
6. Parthenon ܆ Yes ܆ No
7. St. Thomas Midtown
8. St. Thomas Rutherford
Thomas
From__________ To__________ ܆ Yes ܆ No
From__________ To__________ ܆ Yes ܆ No
SAMPLE
11. Southern Hills Medical Center
܆ Yes ܆ No
From__________ To__________ ܆ Yes ܆ No
Center ܆ Yes ܆ No
Center ܆ Yes ܆ No
13. Sumner Regional Medical Center
14. Tennessee Christian Medical Center
From__________ To__________ ܆ Yes ܆ No
From__________ To__________ ܆ Yes ܆ No
15. University Medical Center (Lebanon)
16. Vanderbilt University Medical Center
From__________ To__________
From__________ To__________
܆
܆
Yes
Yes
܆
܆
No
No
17. Vanderbilt Stallworth Rehabilitation Hospital From__________ To__________ ܆ Yes ܆ No
18. VA Medical Center (Nashville)
19. VA Medical Center (Murfreesboro)
20. Williamson Medical Center
From__________ To__________
From__________ To__________
From__________ To__________
܆
܆
܆
Yes
Yes
Yes
܆
܆
܆
No
No
No
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/YY):
Department
To (MM/DD/YY):
Category
Is this your primary facility?
Yes No
Address
City
Phone
State
Fax
ZIP
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
VUMC REAP PROF 20150326
03/24/2015
6 of 16

5($332,170(17$33/,&$7,21)25352)(66,21$/67$))
Hospital Affiliation 2
Facility Name
Med. Staff Office/Verifying Department
Affiliated From (MM/DD/YY):
Department
To: (MM/DD/YY)
Category
Is this your primary facility?
Yes No
Address
City State ZIP
Phone
FAX SAMPLE
Please provide work history since your last appointment with VUMC.
Work History 1
Employer Name
Contact Name Title/Position
Address
City
Phone
Employed From (MM/DD/YY):
Reason for Leaving
Work History 2
Employer Name
Title/Position
Address
City
Phone
Employed From (MM/DD/YY):
Reason for Leaving
State
FAX
To (MM/DD/YY):
Contact Name
State
FAX
To (MM/DD/YY):
ZIP
ZIP
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
VUMC REAP PROF 20150326
03/24/2015
7 of 16

5($332,170(17$33/,&$7,21)25352)(66,21$/67$))
Professional Liability Disclosure Questions
Have any judgments or settlements ever been made against you or on your behalf in professional liability cases?
Are any professional liability claims or cases currently pending?
Yes* No
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 using the enclosed Malpractice Claim Information Worksheet.
Professional Liability Coverage Information
Current Liability Carrier
Carrier Name
City
Beginning with current policy, list ALL of your professional liability carriers for the past 5 years including coverage during graduate training, as applicable.
Address
SAMPLE
State ZIP
FAX
End Date (MM/DD/YY):
Coverage Amount each incident Annual Aggregate Amount
Phone
Issue Date (MM/DD/YY):
Policy Number
Previous Liability Carrier 1
Carrier Name
Address
City
Phone
Issue Date (MM/DD/YY):
Policy Number
Previous Liability Carrier 2
Carrier Name
Address
City
State
FAX
ZIP
End Date (MM/DD/YY):
Coverage Amount each incident Annual Aggregate Amount
State ZIP
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
VUMC REAP PROF 20150326
03/24/2015
8 of 16

5($332,170(17$33/,&$7,21)25352)(66,21$/67$))
Phone
Issue Date (MM/DD/YY):
FAX
End Date (MM/DD/YY):
Coverage Amount each incident Annual Aggregate Amount Policy Number
Previous Liability Carrier 3
Carrier Name
Address
City State ZIP
Phone
Issue Date (MM/DD/YY):
FAX SAMPLE
Coverage Amount each incident Policy Number Annual Aggregate Amount
Provide the name and complete contact information for 1 healthcare provider as a reference from whom we may request specific written feedback.
x All references must be of like degree type or above x Have personal knowledge of your clinical ability, ethical character, professional performance and ability to work cooperatively with others.
x Must not be related to you in any way.
x Reference must have had organizational responsibility for your performance (i.e., preceptor, department chair, section chief, etc.).
Reference
Name Title/Position
At what location/facility did you work with this person?
Address
City
Phone
State
FAX
ZIP
Email
Do or did they provide direct supervision? If “Yes” please provide dates below.
Direct Observation Start Date (MM/DD/YY): End Date (MM/DD/YY):
Yes No
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
VUMC REAP PROF 20150326
03/24/2015
9 of 16

5($332,170(17$33/,&$7,21)25352)(66,21$/67$))
List any new State Professional Licenses that you currently hold (APN, RN, etc.)
License 1
Name (exactly as it appears on license)
Issuing State
Issue Date (MM/DD/YYYY):
Licensing Authority License Number
Expiration Date (MM/DD/YYYY):
License 2
Name (exactly as it appears on license)
Issuing State License Number
Issue Date (MM/DD/YYYY):
Licensing Authority
Expiration Date (MM/DD/YYYY):
SAMPLE
Name (exactly as it appears on license)
License 3
Issuing State Licensing Authority License Number
Issue Date (MM/DD/YYYY):
License 4
Name (exactly as it appears on license)
Expiration Date (MM/DD/YYYY):
Issuing State
Issue Date (MM/DD/YYYY):
Licensing Authority License Number
Expiration Date (MM/DD/YYYY):
Drug Enforcement Administration (DEA) Registration for Prescribers
Name (exactly as it appears on registration certificate) Registration Number
Issue Date (MM/DD/YYYY): Expiration Date (MM/DD/YYYY):
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.
Drug Enforcement Administration (DEA) Registration for NON-Prescribers
For Non-Prescribers Only:
I do not prescribe or write orders for scheduled drugs.
I acknowledge this is prohibited without first obtaining a full schedule DEA.
Yes No
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
VUMC REAP PROF 20150326
03/24/2015
10 of 16

5($332,170(17$33/,&$7,21)25352)(66,21$/67$))
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. State Medical or other Professional License (including any out of state Professional License)? ܆ Yes* ܆ No b. DEA Registration or other applicable controlled substance registration? ܆ Yes* ܆ No c. Hospital or healthcare facility staff membership or privileges? ܆ Yes* ܆ No d. Medicare, Medicaid or other local, state, and/or federal government program participation? ܆ Yes* ܆ No e. HMO, PPO or other health plan participation? ܆ Yes* ܆ 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. Professional committee? ܆ Yes* ܆ No
SAMPLE
܆ Yes* ܆ No
܆ Yes* ܆ No
Program? ܆ Yes* ܆ No e. If others, please specify. _________________________________ ܆ N/A ܆ Yes* ܆ No
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
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
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?
7. Have you ever opted out of Medicare?
܆
܆
Yes*
Yes*
܆
܆
No
No
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.
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.
VUMC REAP PROF 20150326
03/24/2015
11 of 16

5($332,170(17$33/,&$7,21)25352)(66,21$/67$))
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 reappointment, 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.
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
SAMPLE 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.
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.
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:
9$1'(5%,/781,9(56,7<0(',&$/&(17(5
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.
VUMC REAP PROF 20150326
03/24/2015
12 of 16

5($332,170(17$33/,&$7,21)25352)(66,21$/67$))
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.
SAMPLE
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.
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.
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.
VUMC REAP PROF 20150326
03/24/2015
13 of 16

5($332,170(17$33/,&$7,21)25352)(66,21$/67$))
5($332,170(1735272&2/$33529$/)250
$GYDQFHG3UDFWLFH
5HJLVWHUHG1XUVH3K\VLFLDQ$VVLVWDQW
$332,170(1735272&2/$33529$/)250
The accompanying signatures serve to recommend the appointment of ___________________________ SAMPLE as ______________________________ in the Department of __________________________________ for a period not to exceed two years commencing ______________________.
Practice location:
The accompanying signatures serve to confirm THE EXISTANCE OF PRACTICE PROTOCALS ON FILE WITH
CAPNAH. The evidenced based practice protocols/guidelines have been reviewed and approved by both the PROVIDER and supervising physician and are consistent with the PROVIDER’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.
683(59,6,1*3+<6,&,$16
(Name/Title) (Name/Title)
(Date) (Signature) (Date) (Signature)
$3513$$SSOLFDQW
(Name/Title) (Signature) (Date)
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
VUMC REAP PROF 20150326
03/24/2015
14 of 16

5($332,170(17$33/,&$7,21)25352)(66,21$/67$))
(/(0(1762),1)250('&216(17
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”;
SAMPLE
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 perform significant portions of the procedure;
7. 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;
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;
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
VUMC REAP PROF 20150326
03/24/2015
15 of 16

5($332,170(17$33/,&$7,21)25352)(66,21$/67$))
,03257$17127,&(5(*$5',1*,0081,=$7,216
())(&7,9(,00(',$7(/<$//9$1'(5%,/7(03/2<('35$&7,7,21(56
:,//%(5(48,5('72%(&203/,$17:,7+9$1'(5%,/70(',&$/&(17(5
,0081,=$7,216352*5$0$1'78%(5&8/,17%6.,17(67,1*$77+(
7,0(2)7+(,5,1,7,$/$332,170(17255($332,170(17 SAMPLE
)DFXOW\
<RXFDQFKHFN\RXUUHFRUGRIFRPSOLDQFHRQWKH)DFXOW\2ULHQWDWLRQDQG
7UDLQLQJ2IILFHZHEVLWHDW
6WDII
<RXUVXSHUYLVRUFDQFKHFN\RXUFRPSOLDQFHVWDWXVRQ0\9DQG\E\YLHZLQJWKH
³5HFRUGRI&RPSOLDQFHLQ2FFXSDWLRQDO+HDOWK´UHSRUW
(PDLODQ\DGGLWLRQDOTXHVWLRQVWR
,I\RXSUHIHUWRFRQWDFW2FFXSDWLRQDO+HDOWKE\SKRQHSOHDVHFDOO
All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.
VUMC REAP PROF 20150326
03/24/2015
16 of 16

SAMPLE