Application for Initial Medical Staff Appointment Name: _________________________________________________________________ Please attach a recent photo here Application for: Winchester Medical Center Warren Memorial Hospital Attending Staff Attending Staff Courtesy Staff Consulting Courtesy Staff Consulting Courtesy Staff Consulting Shenandoah Memorial Hospital Attending Staff Please return this application and all necessary attachments to: Winchester Medical Center Medical Affairs Office 1840 Amherst Street Winchester Medical Center Winchester, VA 22601 QUALIFICATIONS FOR APPOINTMENT TO THE WINCHESTER MEDICAL CENTER MEDICAL STAFF To be eligible to apply for appointment to the Medical Staff, practitioners must: 1. have a current unrestricted license to practice medicine and a current or pending Virginia license; 2. have current, valid professional liability coverage in a form and in amounts satisfactory to the Hospital; 3. not be excluded or precluded from participation in any government health program: and 4. have never been convicted of any felony relating to the practice of their profession, other health care-related matters, third-party reimbursement, violence, or controlled substances violations; 5. have successfully completed a residency training program approved by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association in a specialty in which the applicant seeks clinical privileges, or a dental surgery training program accredited by the Commission on Dental Education of the American Dental Association, or a podiatric surgical residency program accredited by the Council on Podiatric Education of the American Podiatry Association; and 6. become certified within the time period prescribed by the appropriate specialty board of the American Board of Medical Specialties, the American Osteopathic Association, the American Board of Oral and Maxillofacial Surgery or the American Board of Podiatric Surgery, as applicable, or, if the applicable Board has no such requirements, within five (5) years of becoming qualified. The Hospital Board may grant a waiver in exceptional cases after considering the findings and recommendations of the Staff Executive Committee regarding the specific qualifications of the individual. The individual requesting the waiver shall bear the burden of demonstrating that his or her education, training, experience, and competence are equivalent to board certification. In the event the Board determines not to grant a waiver, the individual shall not be entitled to a hearing. The granting of a waiver shall not be considered a precedent. Applicants who fail to meet these threshold criteria will not be processed, and the individual will be so notified. There is no right to a hearing on a determination of ineligibility. Application for Medical Staff Appointment & Clinical Privileges Name: Date of Application: Instructions 1. All information must be typed or printed 2. If more space is needed, attach additional sheets and make reference to the questions being answered. 3. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED. 4. If not previously provided, please attach copies of the following documents to this application: • Current license(s) to practice your profession • Current DEA registration and state controlled substance license (if applicable) • Current certificate of professional liability insurance coverage from insurance carrier • ECFMG certificate (if foreign medical graduate) • Evidence of successful completion of a residency training program and a copy of the residency log if your residency training was completed within the last five years • Evidence of board certification (if applicable) • Curriculum vitae 5. Please indicate the clinical privilege that you are requesting by completing the attached clinical privilege request form. 6. Submit the completed, signed application form to the Medical Affairs Office, along with all of the requested documentation, any required application processing fees, and the completed clinical privileges request form. I. General Information Name: ________________________________________ Spouse’s Name (if applicable) ________________________________ Home Address: ____________________________________________________________________________ Home Phone No.: _________________________ e-mail: __________________________________________ Birth Date & Place: _________________________________________________________________________ Social Security #: ______________________________ UPIN #: _____________________________________ Medicaid Provider #: ___________________________ Medicare Provider #: ___________________________ Workers’ Compensation Provider #: ____________________________________________________________ Visa Status (if not a U.S. citizen): ______________________________________________________________ II. Private Practice Information Name of Practice: ___________________________________________________________________________ Practice Mode: Solo Group Other: ________________________________________ Others with whom you are associated in practice and nature of association: __________________________________________________________________________________________ __________________________________________________________________________________________ Beeper Number: _________________________________ After-Hours Phone: _________________________ Primary Office Address: _____________________________________________________________________ City: __________________________________________ State _______________ Zip: _________________ Telephone Number: ______________________________ Fax Number: ______________________________ Second Office Address: ______________________________________________________________________ City: __________________________________________ State _______________ Zip: _________________ Telephone Number: ______________________________ Fax Number: ______________________________ Please list the name(s) of at least one medical staff appointee with appropriate clinical privileges who has agreed to provide alternate coverage for your hospitalized patients in the event of your unavailability: __________________________________________________________________________________________ III. Professional Information Please answer each of the following questions. If the answer to any question is yes, please provide a full explanation of the details on a separate sheet and attach. 1. Has your DEA registration or state controlled substance license ever been relinquished, limited, denied, suspended, or revoked, or have any conditions been placed on them? Yes No 2. Is your DEA certificate or state controlled substance license currently being investigated? Yes No 3. Have you ever been suspended, sanctioned, excluded, or otherwise precluded from participating in Medicare, Medicaid, or any other federal, state, or private health insurance program? Yes No 4. Have you ever been the subject of an investigation by any private, federal, or state agency concerning your participation in any private, federal, or state health insurance program? Yes No 5. Have you ever been named as a defendant in any criminal proceeding? Yes No 6. Have you ever been convicted of any felony or any misdemeanor relating to the practice of your profession, other healthcare-related matters, third-party reimbursement, violence, or controlled substances violations? Yes No IV. Education Data A. School Undergraduate College or University Name: __________________________________________________________________________________ Address: __________________________________________________________________________________ Degree: _________________________________________ Graduation Date: __________________________ Medical or Dental School Name: ____________________________________________________________________________________ Address: __________________________________________________________________________________ Degree: _________________________________________ Graduation Date: __________________________ B. Internships List every internship begun or completed. If more than one internship was begun or completed, please supply the same information on a separate sheet and attach. Dates: ________________________ to ________________________ Institution: ________________________________________________________________________________ Address: __________________________________________________________________________________ Phone No.: _____________________________ Type of Internship: __________________________________ Program Director: __________________________________________________________________________ Was the program successfully completed? Yes No C. Residencies List every residency begun or completed. If more than two residencies were begun or completed, please supply the same information on a separate sheet and attach. Dates: ________________________ to ________________________ Institution: ________________________________________________________________________________ Address: __________________________________________________________________________________ Phone No.: _____________________________ Specialty: __________________________________________ Department Chief or Program Director: _________________________________________________________ Was the program successfully completed? Yes No Dates: ________________________ to ________________________ Institution: ________________________________________________________________________________ Address: __________________________________________________________________________________ Phone No.: _____________________________ Specialty: __________________________________________ Department Chief or Program Director: _________________________________________________________ Was the program successfully completed? Yes No D. Fellowships List every fellowship begun or completed. If more than one fellowship was begun or completed, please supply the same information on a separate sheet and attach. Dates: ________________________ to ________________________ Institution: ________________________________________________________________________________ Address: __________________________________________________________________________________ Phone No.: _____________________________ Type of Fellowship: _________________________________ Department Chief or Program Director: ________________________________________________________ Was the program successfully completed? Yes No E. Teaching Appointments List every teaching appointment begun or completed. If more than one teaching appointment was begun or completed, please supply the same information on a separate sheet and attach. Dates: ___________________ to ___________________ Institution: ________________________________________________________________________________ Address: __________________________________________________________________________________ Department Chief of Program Director: ________________________________________________________ Type of Appointment: _______________________________________________________________________ F. Continuing Medical/Professional Education (During past three years) Dates: ___________________ to ___________________ Institution: ________________________________________________________________________________ Address: __________________________________________________________________________________ Course Title: ______________________________________________________________________________ Dates: ___________________ to ___________________ Institution: ________________________________________________________________________________ Address: __________________________________________________________________________________ Course Title: ______________________________________________________________________________ Dates: ___________________ to ___________________ Institution: ________________________________________________________________________________ Address: __________________________________________________________________________________ Course Title: ______________________________________________________________________________ Dates: ___________________ to ___________________ Institution: ________________________________________________________________________________ Address: __________________________________________________________________________________ Course Title: ______________________________________________________________________________ V. Work History List in chronological order your work history and all institutional affiliations since completion of your postgraduate education. This includes all hospitals, corporations, military assignments, or government agencies. Complete addresses must be included. If more space is needed, please attach an additional sheet. This information may be supplemented by, but not replaced by, attaching a copy of your curriculum vitae. Dates: ________________________ to ________________________ Institution: ________________________________________________________________________________ Address: __________________________________________________________________________________ Phone No.: ________________________________________________________________________________ Department Chief: __________________________________________________________________________ Staff Category: _____________________________________________________________________________ Dates: ___________________ to ___________________ Institution: ________________________________________________________________________________ Address: __________________________________________________________________________________ Phone No.: ________________________________________________________________________________ Department Chief: __________________________________________________________________________ Staff Category: _____________________________________________________________________________ Dates: ___________________ to ___________________ Institution: ________________________________________________________________________________ Address: __________________________________________________________________________________ Phone No.: ________________________________________________________________________________ Department Chief: __________________________________________________________________________ Staff Category: _____________________________________________________________________________ If the answer to any of the following questions is yes, please provide a full explanation of the details on a separate sheet and attach. 1. Has your employment, medical staff appointment or clinical privileges, or status as a participating provider in a managed care organization ever been relinquished, withdrawn, suspended, reduced, revoked, denied, not renewed, or subject to probationary or other conditions at any hospital, healthcare facility, or managed care organization, whether voluntarily or involuntarily? Yes No 2. Have you ever withdrawn your application for appointment, reappointment, clinical privileges, or participating provider status in a managed care organization, or resigned before a decision was made by a governing board? Yes No 3. Have you ever been the subject of an investigation at any hospital, healthcare facility, or managed care organization? Yes No 4. Are there presently any proceedings or investigations taking place at any hospital, healthcare facility, or managed care organization relating to your clinical competence or professional conduct? Yes No 5. Have you ever been the subject of focused individual monitoring relating to your clinical competence or professional conduct at any hospital, healthcare facility, or managed care organization? Yes No VI. Ability to Exercise Privileges Are you able to safely and competently exercise the clinical privileges requested and perform the duties and responsibilities of appointment, including, but not limited to emergency service coverage and committee service? Yes No (Note: The Health Status Confirmation Form must also be completed and reviewed prior to final Board action on your application.) VII. Licensure and Professional Associations A. Licensure Please include information for each state in which you currently hold or have held an active license to practice your profession. State License Number Expiration Date _____________________ _____________________ ____________________________ ____________________________ ________________________ ________________________ 1. Have any investigations or disciplinary actions ever been initiated by any state licensure agency or are there any currently pending? Yes No 2. Has your license to practice in any state ever been relinquished, suspended, modified, restricted, or terminated, whether voluntarily or involuntarily? Yes No 3. Have you ever been asked to surrender your license in any state? Yes No 4. Have you ever been reprimanded or otherwise sanctioned, or had conditions placed on your license, by any licensure agency? Yes No B. Membership in Professional Societies (local, state, or national) Name & Address Dates From _______________________________________________________ __________ To __________ _______________________________________________________ __________ __________ _______________________________________________________ __________ __________ _______________________________________________________ __________ __________ Have you ever been denied membership or renewal thereof, or been subject to disciplinary proceedings, in any professional organization? If yes, please provide a full explanation of the details on a separate sheet and attach. Yes No C. Board Certification 1. Names of specialty boards by which you are certified: Name: _____________________________________________ Date: _________________________ Name: _____________________________________________ Date: _________________________ 2. Have you ever been examined by any specialty board, but failed to pass the examination? If yes, please provide a full explanation of the details on a separate sheet and attach. Yes No 3. If not certified, have you applied for the certification examination? Yes No If no, do you intend to apply for the certification examination? Yes No 4. Have you been accepted to take the certification examination? Yes No If yes, what dates are you scheduled to take the certification examination? _______________________________________________________________________________________ 5. Date(s) of next required recertification examination (if applicable): _______________________________ _______________________________________________________________________________________ VIII. Professional Liability Data A. Insurance Present Carrier: __________________________________________________________________________ Address: ________________________________________________________________________________ Level of Coverage: ________________________________________________________________________ Policy Number: ___________________________________ Effective Dates: ______________________ List carriers for the past 10 years: Name: _____________________________________________ Coverage Period _____________________ Address: ________________________________________________________________________________ Name: _____________________________________________ Coverage Period _____________________ Address: ________________________________________________________________________________ 1. Do you have “tail coverage?” Yes No 2. Has your professional liability insurance coverage ever been terminated by action of the insurance company? Yes No 3. Have you ever been denied professional liability insurance coverage? Yes No 4. If you answered yes to either question 2 or 3 above, state when and by what corporation: _______________________________________________________________________________________ 5. Has any professional liability insurance carrier ever excluded any specific procedures from your coverage? Yes No If yes, please list the procedures which have been excluded and provide a full explanation on a separate sheet, including the name of the carrier, the date, and specific information concerning any limitation. 6. Has any insurance company ever imposed a surcharge or additional premium upon you because of your claims history? Yes No B. Legal Actions Please include suits in which a judgement or settlement was made against a professional corporation of which you are or were a member, shareholder, or employee in any matter in which you were involved in the patient’s care. 1. Have any professional liability suits ever been filed against you? Yes No 2. Have any professional liability suits been filed against you which are presently pending? Yes No 3. Have any judgements been made against you, or have there been any settlements involving you, in professional liability cases? Yes No If the answer to any of the above questions is yes, please provide a full explanation of the details of each and every matter on a separate sheet and attach. The explanation must include the name of the court in which the suit was filed, the caption and docket number of the case, the name and address of the attorney defending you, and a description of the case and the status or disposition. IX. References List at least three professional references, not including relatives, current partners, or associates in practice, who have had recent extensive experience in observing and working with you. References will be evaluated according to the extent of their direct clinical observation of your work and other knowledge of you. At least one reference must practice in your clinical specialty. Please provide current, complete addresses. 1. Name: _________________________________________________________________________________ Address: ________________________________________________________________________________ City: ________________________________________ State: _______________ Zip: ______________ Telephone Number: ______________________________________________________________________ 2. Name: _________________________________________________________________________________ Address: ________________________________________________________________________________ City: ________________________________________ State: _______________ Zip: ______________ Telephone Number: ______________________________________________________________________ 3. Name: _________________________________________________________________________________ Address: ________________________________________________________________________________ City: ________________________________________ State: _______________ Zip: ______________ Telephone Number: ______________________________________________________________________ X. Conditions of Application, Release and Immunity A. Conditions of Applications In return for my application being considered and processed, I agree to be legally bound by the following terms and conditions: 1. In understand that it is my responsibility to produce adequate information so that my application can be properly evaluated. In addition to the information provided in this application, I also agree to provide the hospital with any additional information that the hospital or one of its authorized representatives may request. MY FAILURE TO PROVIDE ANY REQUESTED INFORMATION WILL CAUSE MY APPLICATION TO BE INCOMPLETE AND WILL PREVENT IT FROM BEING PROCESSED. 2. I also agree to keep this application current by informing the hospital, through the Chief Executive Officer, or his or her designee, of any changes in the information provided, including, but not limited to, any investigations by a state licensure agency, any change in my professional liability insurance coverage, the filing of a professional liability lawsuit against me, any change in my status at any other hospital, any change in my eligibility for participation in the Medicare or Medicaid programs, and any change in my ability to safely and competently exercise my clinical privileges because of health status issues, including impairment. 3. I will make myself available for interviews in regard to this application. 4. I agree to accept committee assignments, emergency service call obligations, and such other reasonable medical staff duties and responsibilities as shall be assigned to me. 5. I agree to provide timely and continuous care for all my patients treated at the hospital. 6. My appointment to the medical staff and continued clinical privileges remain contingent upon my continued demonstration of professional competence and cooperation, acceptable performance of all related responsibilities, as well as the other factors deemed relevant by the hospital. 7. I have received and have had an opportunity to read a copy of the Medical Staff Bylaws, Rules and Regulations, and Credentialling Policy. I specifically agree to abide by the bylaws, policies, rules and regulations, and directives that are in force during the time I am appointed to the medical staff. 8. I also agree as a condition of appointment, to adhere to the Corporate Compliance Policy for the hospital and any laws, regulations, and standards of conduct applicable to my profession, participation in any federal health program, or activities at the hospital, and to report any known or suspected violation of the same by me or by any officer, director, employee, non-physician practitioner, or other medical staff appointee to the Chief Executive Officer or the Compliance Officer. 9. I represent that all of the information provided in or attached to this application is accurate and complete. I understand and agree that any misrepresentation, misstatement, or omission from this application, whether intentional or not, shall constitute cause for the immediate cessation of the processing of the application and no further processing shall occur. In the event that an appointment has been granted prior to the discovery of such misrepresentation, misstatement, or omission, such discovery may be deemed to constitute automatic relinquishment of my clinical privileges and medical staff appointment. In either situation, I am not entitled to any hearing or appeal rights that are contained in the Credentialling Policy. B. Release and Immunity By applying for appointment and clinical privileges, I accept the following conditions and intend to be legally bound by them, regardless of whether or not I am granted appointment and/or clinical privileges. These conditions shall remain in effect for the duration of any term of appointment that I may be granted. 1. To the fullest extent permitted by law, I extend absolute immunity to, release from any and all liability, and agree not to sue the hospital, its medical staff, their authorized representatives, and appropriate third parties for any matter relating to appointment, reappointment, clinical privileges, or my qualifications for the same. This includes any actions, recommendations, reports, statements, communications, or disclosures involving me, which are made, taken, or received by the hospital, the medical staff, their authorized representatives, or appropriate third parties. 2. I authorize the hospital, its medical staff, and their authorized representatives to consult with any third party who may have information bearing on my professional qualifications, credentials, clinical competence, character, ability to perform safely and competently, ethics, behavior, or any other matter reasonably having a bearing on my qualifications for initial and continued appointment to the medical staff. This authorization includes the right to inspect or obtain any and all communications, reports, records, statements, documents, recommendations or disclosures of said third parties that may be relevant to such questions. In addition, I specifically authorize these third parties to release the information to the hospital, its medical staff, and their authorized representatives upon request. 3. I also authorize the hospital, its medical staff, and their authorized representatives to release such information to other hospitals, healthcare facilities, managed care entities, and their agents, who solicit such information for the purpose of evaluating my qualifications pursuant to a request for appointment and clinical privileges, participating provider status or other credentialling matter. 4. I agree that the hearing and appeal procedures set forth in the hospital’s Credentialling Policy shall be my sole and exclusive remedy with respect to any professional review action taken at the hospital. 5. If, notwithstanding the provisions in this Section B, I institute legal action against the hospital, its medical staff, or their authorized representatives and do not prevail, I agree to reimburse the hospital and any medical staff members who are named in the action for all costs incurred in defending such legal action, including reasonable attorneys’ fees. __________________________________________________ Signature of Practitioner __________________________________________________ Print or Type Name of Practitioner ____________________________________ Date Confidential Peer Review Document Regardless of how these questions are answered, the applicant will be processed in the usual manner. If you have answered these questions and are found to be professionally qualified for medical staff appointment and the clinical privileges requested, you will be given an opportunity to meet with the Credentials Committee to determine what accommodations are necessary or feasible to allow you to practice safely. Health Status 1. Do you have any physical or mental condition which could affect your ability to exercise the clinical privileges requested and perform the duties of staff appointment, or that would require an accommodation in order for you to exercise the privileges requested safely and competently? Yes No 2. Have you been hospitalized at any time during the past five years? Yes No 3. Have you ever been denied health, life, or disability insurance? Yes No 4. Do you have any limitations on your health, life, or disability insurance? Yes No 5. Have you ever had any problems with alcohol or drug dependency? Yes No 6. Are you currently taking any medication that may affect either your clinical judgement or motor skills? Yes No 7. Are you currently under any limitations concerning your activities or work load? Yes No 8. Are you currently under the care of a physician? Yes No If the answer is yes to any question, please explain and submit a report from your treating physician specifically addressing how the condition may affect your ability to exercise the privileges you have requested. Please also explain any proposed accommodation. Affirmation I understand that my appointment and clinical privileges are conditional upon my demonstrating that I am capable of exercising my privileges safely and competently and performing the duties of appointment. I affirm that all my responses provided above are accurate, in accordance with the terms and conditions on the application form I submitted. I understand that the burden is on me to request any proposed accommodation and to justify its reasonableness. ___________________________ Date ______________________________________________ Signature of Practitioner ______________________________________________ Print or Type Name of Practitioner For Hospital Use Only Applicant’s Name: _____________________________________ Date Received: _______________________ Department Chairperson Recommendations The Department Chairperson has reviewed this application, including requested delineation of privileges form, and forwards them to the Credentials Committee with a recommendation of: Approved Disapproved With privileges: As Requested Other (see Delineation of Privileges) In the department of: _____________________________ Subsection of: _____________________________ Date: ________________________ Signed: _______________________________________________ Credentials Committee Recommendations The Credentials Committee has reviewed this application, including requested delineation of privileges form, and forwards them to the Staff Executive Committee with a recommendation of: Approved Disapproved With privileges: As Requested Other (see Delineation of Privileges) In the department of: _____________________________ Subsection of: _____________________________ Date: ________________________ Signed: _______________________________________________ Executive Committee of the Medical Staff Recommendations The Executive Committee of the Medical Staff has reviewed this application, including requested delineation of privileges form, and forwards them to the Board of Trustees with a recommendation of: Approved Disapproved With privileges: As Requested Other (see Delineation of Privileges) In the department of: _____________________________ Subsection of: _____________________________ Date: ________________________ Signed: _______________________________________________ Board of Directors Action The Board of Directors has reviewed the recommendation of the Executive Committee of the Medical Staff and recommends: Appointment Not Appointed Conditions: _______________________________________________________________________________ Date: ________________________ Signed: _______________________________________________