IAC Vein Center
Medical Staff Form
If any current medical staff were not included in the original application, this form must be completed and submitted to the
IAC. An attestation is required and can be found at the end of this form. Please refer to the Vein Center Standards, Section
1.2.2A Medical Staff for additional requirements which will be requested at either a site visit or in addition to this form. To
finalize the process, please enter all of the staff member’s information into the Manage Staff section in your online portal.
1.2A
Medical Staff – This section must be completed (do not submit curriculum vitae):
Name:
E-mail:
Prefix:
Degree:
Dr.
MD
Mr.
DO
Ms.
Facility Name:
Application Number:
Facility Address:
City:
Phone:
State:
Fax:
Zip:
Country:
Is this medical staff member a licensed MD or DO? Applicable Standard: Part A,1.2A
Yes
No
Is this medical staff member’s board certification current? Applicable Standard: Part A,1.2A
Yes
No
1.2.1A Training and Experience:
Indicate in which training and experience pathway this medical staff member is applying:
Applicable Standard: Part A, 1.2.1A
A) Clinical Experience (post residency/fellowship training) in the management and treatment of venous disease.
B) Residency/Fellowship – Successful completion of an Accreditation Council for Graduate Medical Education
(ACGME) approved residency/fellowship for which venous disease, venous interventional treatment and
venous ultrasound training was included in the core curriculum within five years prior to the application date.
Date of completion:
Medical Staff Procedure Volumes
Has this staff member had direct participation in the active vein care of at least 100 cases over the previous three
years in at least one of the four categories? Applicable Standard: Part A, 1.2.1.1A
Yes
No
If no, please explain.
Enter the number of cases in which this staff member has directly participated during the last three years.
Multiple identical procedures done on the same patient at the same time only count as one case.
Sclerotherapy:
Ambulatory Phlebectomy:
Saphenous Vein Ablation:
Non-operative management of chronic venous insufficiency with ulceration (C5 – C6):
Provisional Medical Staff
Is this medical staff member applying as a provisional staff member?
Applicable Standard: Part A, 1.2.3A
Yes
No
IAC Vein Center Medical Staff Form
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The Medical Director may appoint a qualified staff member(s) as provisional staff who meets all required criteria
with the exception of the direct participation in the active vein care case volume and/or distribution criteria as
outlined. The Medical Director will be responsible for review of the provisional staff member including biannual
review of case log including outcomes. The provisional medical staff member must attain full medical staff
membership within three years.
I attest to this provisional status
Signature of Medical Director:___________________________________________ Date: __________
Does this staff member have Basic Life Support and/or Advanced Cardiac Life Support certification?
Yes
No
If no, please refer to Applicable Standard: Part A, 1.2.2.3A
Is this staff member responsible for performing venous evaluation, management and treatment services?
Applicable Standard: Part A, 1.2.4.1A
Yes
No
If no, please explain.
Does this staff member participate in equipment training and inspection to ensure safe operating conditions as
specified by the manufactures guidelines and the Medical Director?
Applicable Standard: Part A, 1.2.4.1A ii
Yes
No
Does this medical staff member participate in the facility’s comprehensive quality improvement program?
Applicable Standard: Part A, 1.2.4.1Aiii
Yes
No
Continuing Medical Education (CME)
The medical staff must show evidence of maintaining current knowledge by participating in CME courses that are relevant to
venous disease, venous interventional treatment and/or peripheral vascular ultrasound. A minimum of 30 CME is required
every three years. Qualifying CME requirements are waived only if this Medical Staff successfully completed an ACGME
approved residency within the previous five years. Applicable Standard 1.2.2.2A ii.
Has this staff member received a minimum of 30 AMA/PRA Category 1 CME credit hours related to venous disease, venous
interventional treatment and/or peripheral vascular ultrasound in the past three years?
Yes
No
If no, please explain:
Please note: A new staff member will not be added to your accreditation application until all information, including CME
data is entered into the staff member’s profile, located in the Manage Staff section of your online portal. List only the
applicable CME course/exam names and enter hours earned in the Vein Center box.
Comment: Documentation of CME hours earned must be on file and available for inspection/auditing purposes. Do not
submit CME certificates or transcript lists unless specifically requested.
Certification by the Medical Staff
I,
, attest that the information provided regarding my experience and involvement with the facility, including all
required documentation either submitted or held for further review as necessitated by the application is accurate, current and
complete.
Date:
Signature: ________________________________
IAC Vein Center Medical Staff Form
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