MEDICAL RESIDENT/STUDENT
ALLIED HEALTH PROFESSIONAL STUDENT
APPLICATION FORM
Please Type or Print Legibly
Name _________________________________ Dates of Rotation at SWMH__________________________
Permanent Home Address: _________________________________________________________________
Permanent Home Phone
__________________________________ SSN ___________________________
Training Program Affiliation: ________________________________________________________________
Program Director Name and Phone Number: ____________________________________________________
Insurance Company: ______________________________________________________________________
Supervising Physician at Southwest Memorial Hospital: ____________________________________________
Birth Date: ________________ Birthplace: __________________ Year in Training: _____________________
Applicant Category:





Emergency Medicine Resident/Student
Family Medicine Resident/Student
General Surgery Resident/Student
Internal Medicine Resident/Student
Allied Health Professional Student
 NP
 PA
- REQUIREMENTS 1.
2.
3.
4.
5.
A signed affiliation agreement between the Hospital and the school, to be kept in the Administrative Offices
Written verification from the training program/school that the individual is a participant in good standing
Documentation of malpractice insurance coverage in the amounts specified by the Hospital’s Governing Board
Documentation of registration with the Colorado State Board of Medicine
Written and signed verification from the supervising physician acknowledging responsibility for the
resident/student
6. Documentation that the supervising physician is registered as such with the Colorado State Board of Medicine
7. Dates of clinical rotation
8. Documentation of health screening consistent with the Human resources/Education Department’s policies
9. Recent photo identification to verify identity, such as driver’s license or passport
10. Verification of clear, completed criminal background check (completed by Medical School, Residency Program
or AHP Program)
11. Current Curriculum Vitae
12. Letter of successful completion from Medical School (Medical Residents only)
Southwest Memorial Hospital
Medical Student Application
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The application and all required documents and information must be fully completed, signed, and received by the Medical
Staff Office before processing may begin. You will not be allowed to function at Southwest Memorial Hospital or any
SWMH affiliate until this information has been received and verified as appropriate. Once the application has been
approved the Medical Staff Office will notify hospital departments that the application is complete.
For each “yes” answer attach a written explanation.
Have any of the following at any time been, or are any currently in the process of being denied, revoked, sanctioned, not
renewed, not completed, suspended, diminished, challenged, withdrawn, terminated, revoked, limited, restricted, placed
on probation or other conditions, placed under disciplinary or investigative action or revoked either voluntarily or
involuntarily in any jurisdiction or country?







Medical or processional license
Clinical privileges
Application/Membership or other rights at any healthcare facility
Employment by any hospital, institution, or the military
Controlled Substance Registration
Participation in any federal, state, or private health insurance program
Participation in any HMO, PPO, or other managed care organization
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 No
 No
 No
 No
 No
 No
 No
1. Have you ever been convicted of a crime (felony or misdemeanor)?
2. Do you have any rehabilitation or other stipulations on your current license?
3. Are you presently the subject of any formal disciplinary proceedings at any
healthcare facility, physician organization, or professional organization?
4. Have you ever been sanctioned by any organization with responsibility
for overseeing the quality, ethics, appropriateness, or other professional
conduct of the medical profession?
5. Are you or have you ever been a party or defendant in any malpractice proceeding?
6. Have you ever been terminated from any medical school or post-graduate program?
Yes
Yes
Yes
 No
 No
 No
Yes
 No
Yes
Yes
 No
 No
- SCOPE OF PRACTICE –
1. Residents/Students shall be supervised by an attending physician/preceptor who is members in good standing of the
Medical Staff.
2. Residents shall consult their attending physician/preceptor on all admissions and patients shall be seen by the
attending physician/preceptor upon admission, or within a reasonable period of time.
3. Patients shall be admitted under the name of the attending physician/preceptor.
4. The supervising physician/preceptor shall see their admitted patients on a daily basis and write appropriate notes and
orders in the patient's chart.
5. Residents may write admitting orders, daily orders, and daily progress notes; these do not have to be cosigned by the
patient’s attending physician/preceptor.
6. Students may write record findings, and write order(s) on charts; any orders made by a medical student must be
immediately countersigned or given verbal approval by the attending physician/preceptor to the RN (Charge nurse)
before the order(s) can be implemented.
7. Residents may dictate admission history and physical notes, operative notes, and discharge summaries. All dictation,
including admission H&Ps and discharge summaries, shall be countersigned by the attending physician/preceptor.
Southwest Memorial Hospital
Medical Student Application
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8. Residents/Students are eligible for specific privileges commensurate with their education and training within the
limitations of those privileges held by the supervising physician/preceptor to whom they are assigned, and with
direct supervision of the attending physician/preceptor, and as determined by the supervising department. Within
these limitations, they may exercise independent judgment within their level of competency, providing that the
supervising physician/preceptor shall have the ultimate responsibility for patient care.
9. Patients have the right to accept or refuse examination by residents/students.
10. Residents/Students shall wear identification badges which clearly identify them accordingly.
11. Residents/Students shall abide by the Hospital and Medical Staff Bylaws, Rules and Regulations and Policies and
Procedures.
12. Residents/Students shall function in cooperation with the Southwest Memorial Hospital Quality Assurance and
Improvement Plan and the Medical Staff Quality Assurance and Improvement Plan.
13. Residents/Students shall comply with all applicable requirements for all legal and regulatory agencies, including but
not limited to, DNV, CMS and the Colorado Board of Medicine.
- ATTESTATION AND AGREEMENT I hereby declare that the above named medical resident will be functioning at Southwest Memorial Hospital under my
direct supervision, will be limited to duties and functions specified above and as outlined in the Medical Staff Bylaws,
Medical Staff Rules and Regulations, and Policies.
I assume full responsibility for the residents/students clinical activities by omission or commission.
I assume the responsibility of advising my patients the identity of the resident/student.
___________________________________________________
Supervising Physician/Preceptor Signature
____________________________
Date
I hereby apply to Southwest Memorial Hospital for appointment as a Medical Resident/Student. I have not requested
privileges for which I am not qualified. I hereby certify that the information contained in this application is complete and
accurate to the best of my knowledge, and acknowledge that any false information or misrepresentation may be grounds
for denial of this application. I have read and understand the information included in the application packet.

I hereby certify that I am capable of performing the essential functions of a physician exercising the privileges for
which I have applied.
 I am in need of a reasonable accommodation, as follows:
________________________________________________________________________________
Are you presently (within the last one hundred eighty days) using any illegal drug or controlled substance?
 Yes  No
_______________________________________________
Signature
____________________________
Date
- APPROVAL ___________________________________________________
Doug Bagge, MD, Chief of Staff
____________________________
Date
____________________________________________________
Kent Helwig, CEO
_____________________________
Date
Southwest Memorial Hospital
Medical Student Application
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