Provider Application
Supplement
PHYSICIAN & PRACTITIONER SERVICES
PINNACLEHEALTH HOSPITALS
307 S. Front Street, 1st Floor
Harrisburg, PA 17104
Fax: 717-231-8588
Heather Johnson, Manager
717-231-8302
hjohnson@pinnaclehealth.org
____________________________________
__________________________
Name of Applicant
Date
Application Fee: (Check made payable to PinnacleHealth Hospitals)
Practitioners employed by PinnacleHealth Systems and practitioners completing residencies with PinnacleHealth
hospitals are exempt from the application fee.
 $300 Application fee for Physicians
 $150 Application fee for Allied Health Providers
All initial appointments to any category of the Medical Staff or Allied Health shall be provisional.
PinnacleHealth Hospitals and its staff will treat this application and all information provided with the strictest of confidenceand will employ safeguards to protect the applicant’s privacy.
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PERSONAL INFORMATION
___________________
________________
Residence Street Address
City
____________________
Email Address
_______
State
_________________
Cell Phone
__________
___________
Zip
Telephone
____________________
Home Phone
____________________
_____________
Birth City
Birth State
_________________
____________________
Birth Country
_____________________________________________
Citizenship
_______________________________________
Languages spoken fluently
_____________________________________________
_________________
Known Aliases
Start Date
________________
End Date
REFERENCES
Please list the names and email addresses of six references that have personal knowledge of your clinical abilities, ethical
character, health status, and ability to work cooperatively with others. The named references must have acquired the
requisite knowledge through recent observation of your professional practice over a reasonable period of time. None of
the individuals should be related to you by family, or by current or impending professional partnership/financial
association. One reference must be your current Department Chairman. (NOTE: Allied Health Providers must
provide at least one Licensed Physician as a reference.) All references must hold the same credentials or greater
credentials than the applicant.
_____________________________________________
_____________
REFERENCE 1) First / Middle / Last Name Degree
_____________________________
________________
Phone
Fax
_________________________________
Email Address
_____________________________________________
_____________
REFERENCE 2) First / Middle / Last Name Degree
_____________________________
________________
Phone
Fax
_________________________________
Email Address
_____________________________________________
_____________
REFERENCE 3) First / Middle / Last Name Degree
_____________________________
________________
Phone
Fax
_________________________________
Email Address
_____________________________________________
_____________
REFERENCE 4) First / Middle / Last Name Degree
_____________________________
________________
Phone
Fax
_________________________________
Email Address
_____________________________________________
REFERENCE 5) First / Middle / Last Name Degree
2
_____________
_____________________________
________________
Phone
Fax
_________________________________
Email Address
_____________________________________________
_____________
REFERENCE 6) First / Middle / Last Name Degree
_____________________________
________________
Phone
Fax
_________________________________
Email Address
RESIDENCY/FELLOWSHIP PROGRAM DIRECTOR
NOTE: THIS SECTION IS TO BE COMPLETED BY PHYSICIANS ONLY.
If you graduated from a residency or fellowship program within the last five years, please complete the following
information.
_____________________________________________
_____________
Program Director Name
______________________
Degree
_________________________________________
Street
__________________
City
_____________________________
________________
Phone
Fax
_______
State
MEMBERSHIP CATERGORY REQUESTED
Active
Active Community (Note: This staff category does not include clinical privileges.)
Affiliate (Note: This staff category does not include clinical privileges.)
Honorary (Note: This staff category does not include clinical privileges.)
Allied Health Professional (CRNP, PA-C, CNM, Genetic Counselor or CRNA, RD, LCSW)
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Zip
_________________________________
Email Address
Please indicate () the Medical Staff or Allied Health Category you seek.





__________
CLINICAL UNIT AFFILIATION REQUESTED
Please indicate () the Principal Department and section in which you are requesting membership based upon your
education and training.
Anesthesiology
Obstetrics and Gynecology
Cardiology
Cardiac Surgery
Vascular Surgery
General Orthopedics
Podiatry
Family Practice
General Pediatrics
Neonatology
Pediatric Cardiology
Pediatric Pulmonology
Laboratories
Radiology
General Internal Medicine
Allergy and Immunology
Dermatology
Endocrinology and Metabolism
Gastroenterology
Hematology/Med Oncology
Infectious Diseases
Medical Toxicology
Nephrology
Neurology
Physical Medicine & Rehabilitation
Psychiatry
Pulmonary/Critical Care
Radiation Oncology
Rheumatology
General Surgery
Neurosurgery
Ophthalmology
Oral Surgery
Otolaryngology
Pediatric Surgery
Thoracic Surgery
Urology
Emergency Medicine
HEALTH STATUS
Are you currently participating/enrolled in a monitoring program for impairment?
YES
or
NO
By signing this application form, I certify that the current statuses of my physical and mental health are commensurate
with the ability necessary to fulfill my Medical Staff membership or Allied Health Status responsibilities and to carry out the
patient care activities related to the clinical privileges requested. I agree that if my physical and/or mental health should be
questioned, in good faith, by the Department Chairperson and the Chief Executive Officer or designee, or the Medical
Executive Committee, I will submit myself to an adequate examination by a qualified examiner who has been mutually
agreed upon by myself and the above persons or committee requesting the examination.
_________________________________________________
___________________________
Signature
Date
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Pennsylvania Standard Application
ADDENDUM TO APPLICATION
Do you have any gaps in clinical activity within the last two years?
IF YOU ANSWER “YES” TO THE QUESTION ABOVE, GIVE FULL DETAILS BELOW:
YES
NO
1. Have you ever been subject to review and/or disciplinary action, formal or informal, by a licensing
board, ethics committee, etc.?
YES
NO
2. Have you ever been found by a state professional disciplinary board to have committed
unprofessional conduct?
YES
NO
3. Have you ever been the subject of reports to a state, federal, national data bank or state licensing
or disciplinary entity?
YES
NO
4. Have you ever been the subject of focused individual monitoring relating to clinical competence or
professional conduct at any hospital, health care facility, or managed care organization?
5. Have you ever been subject to a performance improvement plan at any hospital, health care facility,
or managed care organization?
YES
NO
YES
NO
6. Have you ever had your employment by any hospital, health systems, provider groups, institution or
the military revoked, suspended, limited, denied, placed on probation, disciplinary probation or
terminated?
YES
NO
7. Has your contract for employment not been renewed?
YES
NO
YES
NO
a. Do you have notice of any such anticipated charges?
YES
NO
b. Are you currently under governmental investigation?
YES
NO
YES
NO
1. Are any of the privileges you are requesting not covered by your current malpractice coverage?
YES
NO
2. Has any professional liability carrier ever excluded any specific procedures from your malpractice
coverage?
YES
NO
3. Has any professional liability carrier ever imposed a surcharge or additional premium due to your
claim history?
YES
NO
4. Have you ever settled or dropped any malpractice cases against you?
YES
NO
Attestation Questions
PROFESSIONAL SANCTIONS
If so please provide an explanation
_____________________________________________________________________________
8. How many times have you taken the Board Exam for your Specialty?
_____________________________________________________________________________
9. What is your success rate?
_____________________________________________________________________________
CRIMINAL HISTORY
1. Have you ever been charged with a criminal violation resulting in a plea bargain, conviction on any
charges, or payment of a fine, suspended sentence, community service or other obligation?
AFFIRMATION OF ABILITIES
1. Do you have, or have you had, in the last two years any physical condition or chemical dependency
condition (alcohol or substance abuse) that affects or will affect your current ability to practice with
or without reasonable accommodation?
LITIGATION AND MALPRACTICE COVERAGE HISTORY
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PINNACLEHEALTH SYSTEM
TB Testing Requirements for the Medical/Allied Health Staff
Active Medical Staff and Allied Health Staff members must attest to one of the following for initial appointment and
reappointment. Failure to attest to one of the following would result in an incomplete application.

Negative TST (Tuberculin Skin Test) in the past two (2) years .

Newly positive TST, followed by a negative chest x-ray and evaluation for INH prophylaxis.
Date of positive TST test: ______________________

History of positive TST and negative follow-up chest x-ray with no signs or symptoms of TB in the past two
(2) years.
Date of positive TST __________________________
Date of follow-up chest x-ray ____________________

History of positive TST and signs or symptoms of TB were exhibited in the past two (2) years.
(This information will be forwarded to the PinnacleHealth System Epidemiologist for follow up.)

Newly positive TST, followed by a positive chest x-ray.
(This information will be forwarded to the System Epidemiologist for follow up.)
_______________________________________________
Practitioner Name
_______________________________________________
______________________________
Signature
Date
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PINNACLEHEALTH SYSTEM
PRACTITIONER ACKNOWLEDGMENT STATEMENT
_____________________________________________________________________________________
Practitioner Name
NOTICE TO PRACTITIONER:
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 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 fines, imprisonment or civil
penalties under applicable Federal laws.
NOTICE TO PRACTITIONER:
Medical Assistance 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 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 State or Federal funds may be subject to fines,
imprisonment or civil penalties under applicable State or Federal laws.
NOTICE TO PRACTITIONER:
Champus 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 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 the payment of Federal funds, may be subject to fines, imprisonment or
civil penalties under applicable Federal laws.
I understand that the PinnacleHealth System has adopted a Corporate Integrity Program. A copy of the policy
describing this program has been provided to me. I will not engage in conduct which is proscribed by the Corporate
Integrity Program. I will immediately report to PinnacleHealth Hospitals' Department of Medical Affairs any sanctions
that have been imposed upon me by any State or Federal government agency or by any State or Federal court
regarding my participation in any State or Federal third party payment or reimbursement program including, but not
limited to, Champus, Medicare or Medical Assistance.
I certify that I have read and understand the statements set forth above.
_______________________________________________
______________________________
Signature
Date
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PINNACLEHEALTH SYSTEM
PHARMACY SIGNATURE SHEET
(Practitioner Name, please print)
(Practitioner Signature)
(Practitioner DEA Number)
(Practitioner License Number)
cc: Pharmacy - HH (Jo Vogelsong)
Trish Stoltzfus – HH – North Building Basement
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FACT SHEET FOR PHYSICIANS ON RESTRAINT AND SECLUSION
PinnacleHealth restricts the use of restraint and seclusion to the Emergency Department at both sites, the ICU at both
sites, and 10 North at Harrisburg.
The Attending of Record must be notified “as soon as possible” if restraint or seclusion is ordered on his or her patient
by any other physician; this cannot wait until morning.
There are two sets of rules that must be followed – one is for violent patients, and the other is for non-violent patients.
These are the two categories recognized by JCAHO and CMS.
Restraint for control of violent behavior requires a one to one sitter for the entire duration; seclusion requires one
to one observation for the first hour, after which audio-visual continuous monitoring is OK.
Adult patients in restraint or seclusion for violent behavior must be seen and evaluated every 8 hours by a physician,
and at least once daily by the Attending, with a Progress note to this effect in the chart. Adolescents must be seen
every 4 hours, and children every two.
The Progress note must reference the relevant condition of the patient, the need for continued restraint, and the effect
of the restraint upon the patient. This note is in addition to the order itself. It should also address the underlying cause
of the violence, so that actual treatment to resolve the condition can be instituted.
Patients in non-violent restraint must be seen and evaluated daily by the attending, with a Progress note to this
effect in the chart (see above).
Restraint or seclusion must never be ordered prn. All orders must be on specially designed order sheets.
I affirm that I have reviewed these rules.
_______________________________________________
Practitioner Name
_______________________________________________
______________________________
Signature
Date
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PINNACLEHEALTH SYSTEM
Non-Employee Confidentiality and Security Access Agreement
I, the undersigned, acknowledge and accept the PinnacleHealth System (PHS) terms listed below, and understand that:
1. My PHS Security Access Code is the equivalent of my signature.
2. I will not disclose my PHS Security Access Code to anyone.
3. I will not leave a terminal/ PC unattended with my PHS Security Access Code and menu available.
4. I will not attempt to learn another end-user's PHS Security Access Code.
5. I will not attempt to access information in a PHS system by using a PHS Security Access Code other than my own.
6. I will not attempt to access any unauthorized information via a PHS system or via a PHS system generated report.
7. I will not distribute reports or downloaded files from PHS systems to unauthorized personnel, nor will I use said
reports or downloaded files for purposes other than those for which they were intended.
8. If I access PHS systems through remote access, I will not disclose either the telephone numbers or the additional
security access codes for dial-up.
9. If I download data from a PHS System into my PC, I understand that I am responsible for protecting the information
from any unauthorized persons.
10. If I have reason to believe that the confidentiality and security of my PHS Security Access Code has been breached, I
will contact the Information Services Department immediately so that my Security Access Code can be deleted and a
new code assigned to me.
11. I realize that the patient information that I find in a report, on a chart, or in the system is confidential and is not to be
shared with unauthorized persons.
12. I have read and understand that I must adhere to the Internet/Intranet and E-mail Access Policy of the PinnacleHealth
Privacy Manual if accessing the Internet using a PHS computer.
13. I have read and understand that I must adhere to Computer Software Duplication Policy # 579 of PinnacleHealth's
Administrative Policy and Procedure Manual.
I understand that if I violate any of the above provisions, I will immediately lose the privilege of system access.
I further understand that my PHS Security Access Code will be deleted from the PHS systems as soon as I cease my
association with PinnacleHealth. I further understand that PinnacleHealth may at any time, and for any reason, or for no
reason, remove my access to PinnacleHealth computer systems.
_____________________________________________
First / Middle / Last Name
_________________________
__________________
Date
Signature of Person Requesting Access to PHS Systems
_________________________
_________________ _____________
Date
Signature of Witness
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________________________
_____________
Title
RELEASE
By applying for appointment to the Medical Staff or Allied Health Staff of PinnacleHealth Hospitals and by signing this
application form, I hereby:

signify my willingness to appear for interviews in regard to my application;

acknowledge that I as an applicant for Medical Staff membership/Allied Health Staff and/or privileges have the
burden of producing the requested information for a proper evaluation of my professional, ethical and other
qualifications for membership and clinical privileges and for resolving any doubts about such qualifications;

authorize PinnacleHealth Hospitals and its representatives to consult with my prior associates and others
including members of medical staffs of other hospitals with which I have been associated and with others who
may have information bearing on my professional competence, character, health status, ethical qualifications and
ability to work cooperatively with others;

authorize PinnacleHealth Hospitals, and its representatives to include a photo provided by applicant on the
release form included with all verifications to Medical Schools, Internship programs, Residency programs,
Professional Reference and current and previous hospitals affiliations;

consent to the inspection by PinnacleHealth Hospitals, its Medical Staff and their representatives of all records
and documents that may be material to an evaluation of my professional qualifications and clinical competence
necessary to carry out the clinical privileges that I have requested, as well as my moral and ethical qualifications
for staff membership;

consent to the release of the above information;

release from any liability any and all individuals and organizations who provide information to PinnacleHealth
Hospitals for their acts performed in good faith and without malice in connection with evaluating my credentials,
competence, ethics, character and other qualifications for staff appointment and clinical privileges, including
otherwise privileged or confidential information;

release from liability all representatives of PinnacleHealth Hospitals and its Staff for their acts performed and
statements made in good faith and without malice and in connection with evaluating my application and my
credentials and qualifications;

acknowledge that I have received, or been given access to, and read the Bylaws of the Medical Staff and any
other manuals and policies relevant to the application process and generally to clinical practice at PinnacleHealth
Hospitals, and agree to be bound by the terms thereof in all matters relating to Medical Staff membership/Allied
Health Staff and clinical privileges and to the consideration of my application for appointment to the Medical
Staff/Allied Health Staff and clinical privileges;

pledge to maintain an ethical practice, to provide for continuous care for my patients, and to refrain from
delegating the responsibility or care of my patients to any practitioner not qualified to undertake that responsibility;
and

acknowledge that any significant misstatements in or omissions from this application constitute cause for denial of
appointment or cause for summary dismissal from the Medical Staff/Allied Health Staff.
All information by me in this application is true to the best knowledge and belief.
Photograph
__________________________________________
Signature
_______________________________________
Date
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Photograph