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
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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: _______________________________________________