COLORADO HEALTH CARE PROFESSIONALS APPLICATION
MONTROSE MEMORIAL HOSPITAL INFORMATION SHEET
NAME: __Bryce Lokey, M.D.
___________
Title (MD, DO, other)____________________
Date of Birth: __________________________________
Place of Birth: _________________________
Marital Status: _________________________________
(optional)
____________________________________
Name of spouse/significant other (optional)
Check the category that describes your professional status:
_____ ACTIVE MEDICAL STAFF
Active Staff shall consist of practitioners (i) who are involved in a minimum of fifty (50) patient contacts at the Hospital
or a Hospital sponsored facility, over a 24-month period. A patient contact is defined as any inpatient admission, inpatient
consultation (including radiology and pathology services), treatment of a patient in the Emergency Department, a
procedure performed in the Hospital or a Hospital sponsored facility, or a day on the Medical Staff call schedule.
Members may be appointed to this category at initial appointment where it is anticipated they will meet this criterion. If
they have not completed 25 contacts in their first twelve months on staff, their category status will be changed to
associate. Otherwise, after initial appointment, category status will be assigned at reappointment time based on contact
activity during the previous 24-month period.
_____ ASSOCIATE MEDICAL STAFF
Associate Staff shall consist of practitioners who are interested in the clinical affairs of the Hospital and maintain
privileges to actively manage patient care or to refer and follow hospitalized patients. Associate Staff shall admit or
otherwise be involved in the care or treatment of less than fifty (50) patient contacts (as defined in Section 2.4.1. (a) under
the active category) in an appointment period. Associate Medical Staff shall engage in the active practice of medicine at a
private office or an accredited/licensed healthcare facility other than the Hospital so that the Medical Staff and Board can
assess the practitioner’s compliance with membership and privileging requirements as stated under these Bylaws and
Medical Staff policies.
_____ HONORARY MEDICAL STAFF
The Honorary staff category is restricted to those individuals the Medical Staff wishes to honor; including, but not limited
to those practitioners who have actively participated in Hospital affairs, committee activity and who may have had a
Medical Staff leadership role. Members on the Honorary Staff do not need to be in the active practice of medicine and do
not need to maintain board certification. Honorary staff members shall not be eligible to admit patients to the Hospital or
to exercise clinical privileges in the Hospital, or vote at any meetings attended or hold office. Honorary staff members
may, however, attend Medical Staff and clinical service meetings, educational programs, and social functions. They may
also be appointed as non-voting members of committees when interested so that the Medical Staff may take advantage of
their unique experience or talents.
_____ ADVANCED PROFESSIONAL PRACTITIONERS
Individuals, other than a licensed physician, who provides direct patient care services at Montrose Memorial Hospital
under a defined degree of supervision, collaboration or oversight by a physician who has been granted clinical privileges.
Advanced Professional Practitioners (APPs) exercise judgment that is within the areas of documented professional
competence and is consistent with the applicable State Practice Act. APPs may be employed by or contracted by the
Hospital or may be employed by, or contracted by a physician granted privileges at the Hospital.
Colorado Health Care Professionals Application
Montrose Memorial Hospital Information Sheet
Page 2
QUESTIONS PERTINENT TO MONTROSE MEMORIAL HOSPITAL MEDICAL STAFF:
Please attach full explanation for any “yes” response:
1. Have you ever engaged in any behavior or experienced any mental or physical health condition that might impair your
ability to practice medicine safely or competently?
Yes ____ No ____
2. Have you been hospitalized or have you been institutionalized during the past 10 years?
Yes ____ No ____
3. Have you missed 30 or more consecutive days of work or training since your residency due to illness, injury or a
mental or physical health condition?
Yes ____ No ____
4. Have you changed the scope of your practice due to health problems at any time?
Yes ____ No ____
5. Are you currently taking any medication that might affect either your clinical judgment or motor skills?
Yes ____ No ____
6. Do you or an immediate family member have a conflict of interest as defined in the Medical Staff Conflict of Interest
Policy (8.0) – a situation that raises concerns about the objectiveness of a provider’s judgment and decision-making
with respect to patient care and the business affairs of the Hospital?
Yes ____ No ____
Signature: ______________________________________________ Date: _______________________