February 17, 2016
Dear Physician:
Thank you for your interest in applying for medical staff membership and clinical privileges at Minden Medical Center.
Please find enclosed an application for medical staff membership, request for clinical privileges in your specialty, and
our hospital bylaws, rules, and regulations.
Please read all documents carefully before completing the application and request for clinical privileges. Our governing
board developed the following general standards for applicants. These general standards were adopted to assist
Minden Medical Center in achieving an appropriately high standard of patient care. Please be aware that these are
minimum standards. Upon receipt of your completed application, our credentials committee will conduct a further
review of your credentials before making a recommendation to our governing board. To qualify to apply to our medical
staff you must :
1. Be determined, on the basis of documented references, to adhere strictly to the ethics of your respective
profession(s), to work cooperatively with others and to be willing to participate in the discharge of staff
responsibilities;
2. Comply and have complied with federal, state and local requirements, if any, for their medical practice, are not
and have not been subject to any liability claims, challenges to licensure, or loss of Medical Staff membership or
privileges which will adversely affect their services to the Hospital ;
3. Be currently licensed to practice in this state with no restrictions ;
4. Maintain professional liability insurance in the amount specified by Minden Medical Center’s governing board
5. Have skills and training to fulfill a patient care need existing within the Hospital, and be able to adequately
provide those services with the facilities and support services available at the Hospital ; and
6. Agree to comply with all hospital policies, rules, and regulations, and the hospital code of ethical conduct
If you meet all the above requirements, carefully review all the enclosed materials and complete the enclosed
application and request for clinical privileges. Please return the documents to me 90 days prior to working at Minden
Medical Center, along with full payment of the application processing fee (for Courtesy privileges ONLY: $275 for Initial
Appointment), payable to Minden Medical Center. If you have any questions or require additional assistance, please do
not hesitate to contact the medical staff office.
Sincerely,
Shannie Simon
Medical Staff Coordinator
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 1 of 19
Physician Credentials Application
Please complete ALL sections of application. « SEE CV » sections will be returned.
M.S. Office use: Initial Application
Appointment Period:
Date of Application:
through
GENERAL INFORMATION
LAST NAME:
FIRST:
MIDDLE:
Prof. Designation: M.D. / D.O. / D.P.M. / O.D. / D.D.S.
Sex:  Male
Other Names Used:
Spouse Name:
MAIDEN:
 Female
Foreign Languages (spoken fluently by physician):
DOB:
SSN:
Citizenship:
Specialty:
Birth Place:
Subspecialties:
Home Mailing Address:
City:
State:
Zip:
Home Telephone #:
Cell Phone #:
Home Fax #:
Email Address:
OFFICE/PRACTICE INFORMATION
Practice Name:
Department Name: (if applicable)
Primary Office Street Address:
City/State/Zip:
Office Phone #:
Office Fax #:
Office Manager:
Office Manager Email Address:
Secondary Office Street Address:
City:
State:
Secondary Office Manager:
Zip:
Secondary Office Phone #:
Secondary Office Fax #:
MILITARY SERVICE
Branch:
Dates:
Rank:
Type of Discharge:
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 2 of 19
HEALTH STATUS
Are you able to safely perform all of the essential mental and physical functions related to the specific clinical
privileges you are requesting? If not, on a separate sheet of paper, please describe the essential functions
and state the reason why you may not be able to perform them?
 Yes
 No
Does your physical or mental health affect your ability to practice medicine in such a way that others could
be exposed to health or safety risks? If yes, please explain the nature of the health and safety risk on a
separate sheet.
 Yes
 No
Do you currently or have you ever engaged in the abuse of alcohol or the unlawful use of drugs, including the
use of addictive prescription drugs not under the supervision of a licensed health care professional other
than yourself? If yes, please explain on a separate sheet.
 Yes
 No
PROFESSIONAL REFERENCES
Please list three (3) professional peers who have personal knowledge of your current clinical abilities, ethical character, and ability to
work cooperatively with others. These should be individuals who will provide specific written comments on these matters upon
request. The named individuals must have acquired the requisite knowledge through observation of your professional practice in the
past three (3) years. These peers should be in the same specialty and/or the same field. None of your references should be relatives.
Name & Title of Peer:
Specialty:
Mailing Address:
Phone #:
Fax #/Email Address:
Name & Title of Peer:
Specialty:
Mailing Address:
Phone #:
Fax #/Email Address:
Name & Title of Peer:
Specialty:
Mailing Address:
Phone #:
Fax #/Email Address:
Name & Title of Peer:
Specialty:
Mailing Address:
Phone #:
Fax #/Email Address:
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 3 of 19
PROFESSIONAL EDUCATION
List All Medical Schools/Institutions Attended. Please explain any 6 month or greater gap in your training. Attach additional sheets if
necessary.
Institution:
Degree Earned:
Dates Attended (Month/Year):
Mailing Address:
City:
State:
Zip:
If you are a Graduate of a Foreign Medical School, are you certified by the Education Council for Foreign Medical Graduates (ECFMG)? If
yes, Please enclose a copy of your certificate with this application.  Yes  No
POST GRADUATE TRAINING: INTERNSHIP
Institution:
Program Director/Department Chair:
Dates Attended (Month/Year):
Type of Internship (Rotating/Straight) – If Straight, Please list specialty:
POST GRADUATE TRAINING: RESIDENCY (If more than one, please supply information on a separate sheet.)
Institution:
Program Director/Department Chair:
Dates Attended (Month/Year):
Type of Residency:
POST GRADUATE TRAINING: FELLOWSHIP (If more than one, please supply information on a separate sheet.)
Institution:
Program Director/Department Chair:
Dates Attended (Month/Year):
Type of Fellowship/Other Explanation:
HOSPITAL AFFILIATIONS: PRIMARY
Please list in reverse chronological order (with current affiliation (s) first) all institutions where you have current affiliations (A) and have
had previous hospital privileges (B). This includes hospital, surgery centers, institutions, corporations, military assignments, or
government agencies. If an institution is no longer inexistence, please provide an alternative source of verification. If you do not have
hospital privileges, please explain on a separate sheet. Please attach a current CV and explain any gaps in excess of six (6) months.
Use “Hospital Affiliations” Addendum on page 12, if necessary.
Name and Mailing Address of Primary Admitting Hospital:
City:
Telephone #:
Fax#:
State:
Zip:
Department/Status (active, provisional, courtesy, consulting, temporary, etc)
Appointment Dates:
Any Past or Present Restrictions of Privileges?  Yes  No (IF YES EXPLAIN)
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 4 of 19
PROFESSIONAL CERTIFICATES/LICENSE NUMBERS
LA State:
License #:
Expiration Date:
DEA #
Expiration Date:
CDS #
Expiration Date:
ECFMG#:
NPI #:
Medicaid #:
OTHER STATE MEDICAL LICENSES
State:
License #:
Expiration Date:
State:
License #:
Expiration Date:
OTHER CERTIFICATIONS
Type:
Expiration Date:
Type:
Expiration Date:
Type:
Expiration Date:
Type:
Expiration Date:
BOARD CERTIFICATIONS
Are you certified by a recognized board of the American Board of Medical Specialties (ABMS) or the American Osteopathic Association
(AOA)?  Yes  No; If not applicable to your profession/specialty, complete with N/A. Attach copy of certificate (s).
Name of Issuing Board:
Specialty:
Date Certified:
Recertified:
Expiration Date (if any):
MALPRACTICE COVERAGE (Please attach a copy of your current certificate)
Name of Present Carrier:
Policy #:
Complete Address:
Coverage Amounts:
Phone #:
Fax #
Name of Previous Carrier:
Policy #:
Complete Address:
Coverage Amounts:
Phone#:
Fax#:
Dates of Coverage:
Dates of Coverage:
If you answer “Yes,” please to question #1 or 2, then please use the enclosed Professional Liability Addendum on page 14.
1. Has your professional liability insurance ever been terminated, not renewed, restricted, or modified (e.g. reduced
limits, restricted coverage, surcharged), or have you ever been denied professional liability insurance, or has any
professional liability carrier provided you with written notice of any intent to deny, cancel, not renew, or limit
your professional liability insurance or its coverage of any procedures?
2. Have you ever been a party to any lawsuit, including, but not limited to any professional liability claims or lawsuits
brought against you, including pending claims or lawsuits, dismissed or dropped claims or lawsuits, settlements or
final judgments? If yes, please provide the following items for each matter: (i) the parties to the lawsuit; (ii) the
date the lawsuit was filed; (iii) the court in which the lawsuit was filed; (iv) a description of the nature of the
lawsuit and the claims made by the parties; and (v) the outcome of the lawsuit and the date in which it was
resolved. Additionally, if the lawsuit involved medical malpractice, please complete the Addendum attached.
 Yes  No
 Pending
 Yes  No
 Pending
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 5 of 19
STATEMENT OF AUTHORIZATION & RELEASE FROM LIABILITY (Please complete entire sheet)
Name of Insurance Carrier:
Address of Carrier:
Fax Number:
Policy #
I, Dr.
, am applying for appointment to the Medical Staff of
Minden Medical Center and hereby authorize my Carrier to release to the Hospital all information regarding
my Claims History, including but not limited to:
1.
2.
3.
Judgements entered
Claims settled, and
Cases and lawsuits pending
Please return this information to:
Minden Medical Center
Attn: Medical Staff Department (Shannie G.)
P.O. Box 5003
Minden, La 71058-5003
(318) 371-3239 fax
In authorizing the release of such information to the Hospital, I hereby release you from liability and
indemnify you for acts performed in good faith and without malice in connection with supplying of this
information needed for the processing of my application for appointment to the Medical Staff of Minden
Medical Center. I also request that Minden Medical Center be added as a certificate holder and be mailed
updated malpractice certificates as they are renewed.
Physician Signature
Date
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 6 of 19
PROFESSIONAL PRACTICE QUESTIONS
Please answer the following questions. Note that “N/A” is not an acceptable response. If you answer YES to any question,
you must provide an explanation on a separate sheet of paper.
1. Has your membership, participation, clinical privileges, or employment ever been denied,
terminated, stipulated, restricted, refused, limited, suspended, revoked, or not renewed by any
peer review organization, third party payer, clinic, hospital, medical staff, or any health-related
agency or organization, or is there a review pending?
2. Has your certificate or participation in any private, federal (i.e. Medicare, Medicaid, etc.) or state
health insurance program ever been revoked or otherwise limited or restricted, or is any
investigation or proceeding with respect to any such action presently underway?
3. Are there any charges pending or are you currently charged with or have you ever been indicted or
found guilty of a felony, misdemeanor (other than a minor traffic violation), or other offense
involving fraud, misrepresentation, dishonesty or deceit?
4. Have you ever been subject to investigation by a governmental entity that could result in sanctions
or licensure adverse actions?
5. Have you ever been reprimanded, censored, or otherwise disciplined by, or have you ever been
subject to a corrective action agreement/plan with any licensing board, peer review organization,
third party payer, clinic, hospital, medical staff, or any health-related agency or organization?
6. Have your privileges at any healthcare entity ever been voluntarily or involuntarily suspended,
restricted, diminished, revoked or not renewed, except for medical records?
7. Have you ever resigned from a healthcare entity to avoid modification, suspension, or termination
of privileges?
8. Has your professional license or registration in any jurisdiction ever been terminated, stipulated,
limited, restricted, conditioned, investigated, voluntarily or involuntarily limited, suspended or
revoked, or not renewed by any licensing board of any health-related agency or organization, or
are any currently held licenses pending investigation or being challenged?
9. Have you ever been notified to appear before any licensing agency for a hearing or complaint of any
nature?
10. Has your federal or state narcotics registration certificate in any jurisdiction ever been voluntarily or
involuntarily limited (stipulations), suspended, revoked, restricted, or surrendered, or is it currently
being challenged?
11. Do you know of any reason why you cannot perform the essential duties of the clinical
privileges/functions which you are requesting with or without a reasonable accommodation
according to acceptable standards of professional performance and without posing a direct threat
to patients?
12. Do you use illegal drugs or have you illegally used drugs in the past five years?
 Yes  No  Pending
 Yes  No  Pending
 Yes  No  Pending
 Yes  No  Pending
 Yes  No  Pending
 Yes  No  Pending
 Yes  No  Pending
 Yes  No  Pending
 Yes  No  Pending
 Yes  No  Pending
 Yes  No  Pending
 Yes  No  Pending
I hereby affirm that the information submitted in this Section, Professional Practice Questions, and any addenda thereto is true,
current, correct, and complete to the best of my knowledge and belief and is furnished in good faith. I understand that material,
omissions or misrepresentations may result in denial of my reapplication or termination of my privileges/employment.
Signature:
Printed Name:
Date:
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 7 of 19
MEDICARE – CHAMPUS STATEMENT
, MD
PHYSICIAN NAME
LICENSE NUMBER
MEDICARE
“Notice to Physicians: 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 to 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, maybe subject to fine,
imprisonment, or civil penalty under applicable Federal Laws.”
I, __
MD, certify that I have received the above statement.
Signature:
Printed Name:
Date:
CHAMPUS
“Notice to Physicians: 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 to 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, maybe subject to fine,
imprisonment, or civil penalty under applicable Federal Laws.”
I, _
, MD, certify that I have received the above statement.
Signature:
Printed Name:
Date:
NOTE: THIS FORM IS ONLY FOR APPLICANTS APPLYING FOR ACTIVE AND COURTESY PRIVILEGES
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 8 of 19
CONTINUING EDUCATION
Each licensing board has specific requirements governing the amount of CME credits (20.0) needed each year to
maintain current licensure.
Please list below the courses completed, and the location, date and the number of
These courses must be specialty
specific. If necessary, use an additional sheet, and please send a copy of your listing of courses or
certificates. If just out of Residency or Fellowship, please indicate that below then sign and date the form.
hours of CME credits you have obtained during the past 2 (two) years.
Course Taken
Location
Date
Number of
CME Hours
100% of CMEs is required. Please indicate on the line below.
During the past two years, _________ % of my continuing medical educational activities was related to the
privileges requested. I hereby certify that within the past two years I have completed at least the minimum
number of hours of continuing education credits (20 CMEs per year) required by the board through which I
am licensed, and have participated in all performance improvement activities as specified by Minden Medical
Center. If audited, I will be able to provide documentation of the seminars or courses attended. I recognize
that failure to produce documentation upon request will jeopardize my membership on the medical staff.
Signature:
Printed Name:
Date:
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 9 of 19
MINDEN MEDICAL CENTER
DESIGNATION AND AUTHORIZATION FOR RELEASE (“Release”)
Authority to Release: I hereby apply for Medical Staff appointment to MINDEN MEDICAL CENTER as requested in this application
and, whether or not my application is accepted; I acknowledge, consent and agree as follows:
As an applicant for appointment, I have the burden for producing adequate information for proper evaluation of my qualifications. I
also agree to update the Hospital with current information regarding all questions contained in this application as such information
becomes available and any additional information as may be requested by the Hospital or its authorized representatives. Failure to
produce any such information will prevent my application for appointment from being evaluated and acted upon. I hereby signify
my willingness to appear for the interview, if requested, in regard to my application.
Information given in or attached to this application is accurate and complete to the best of my knowledge. I fully understand and
agree that as a condition to making this application, any misrepresentations or misstatement in, or omission from it, whether
intentional or not, shall constitute cause for automatic and immediate rejection of this application, resulting in denial of
appointment and clinical privileges. I further acknowledge that if it has been reasonably determined that I have made a
misstatement, misrepresentation, or omission in connection with an application that is discovered after appointment and/or the
granting of clinical privileges, I shall be deemed to have immediately relinquished my appointment and clinical privileges.
(1)
I extend immunity to, and release from any and all liability, the Hospital, its authorized representatives and any third
parties, as defined in subsection (3) below, for any acts, communications, recommendations or disclosures performed
without intentional fraud or malice involving me; performed, made, requested or received by this Hospital and its
authorized representatives to, from or by any third party, including otherwise privileged or confidential information,
relating, but not limited to, the following:
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(k)
applications for appointment or clinical privileges, including temporary privileges;
periodic reappraisals;
proceedings for suspension or reduction of clinical privileges or for denial or revocation of
appointment, or any other disciplinary action;
summary suspension;
hearings and appellate reviews;
medical care evaluations;
utilization reviews;
any other Hospital, Medical Staff, department, service or committee activities;
inquiries concerning my professional qualifications, credentials, clinical competence, character,
mental or emotional stability, physical condition, ethics or behavior; and
any other matter that might directly or indirectly impact or reflect on my competence, on patient
care or on the orderly operation of this or Hospital.
(2)
I specifically authorize the Hospital and its authorized representatives to consult with any third party who may have
information, including otherwise privileged or confidential information, bearing on my professional qualifications,
credentials, clinical competence, character, mental or emotional stability, physical condition, ethics, behavior or other
matter bearing on my satisfaction of the criteria for continued appointment to the Medical Staff, as well as to inspect or
obtain any all communications, reports, records, statements, documents, recommendations and/or disclosure of said third
parties relating to such questions. I also specifically authorize said third parties to release said information to the Hospital
and its authorized representatives upon request.
(3)
The term “Hospital” and “its authorized representatives” means the Hospital corporation, the Hospital to which I am
applying and any of the following individuals who have any responsibility for obtaining or evaluating my credentials, or
acting upon my application or conduct in the Hospital: the members of the Board and their appointed representatives, the
CEO or his/her designees, other Hospital employees, consultants to the Hospital, the Hospital’s attorney and his/her
partners, associates or designees, and all appointees to the Medical Staff. The term “third parties” means all individuals,
including appointees to the Medical Staff, and appointees to the Medical Staffs of other Hospitals or other physicians or
health practitioners, nurses or other government agencies, organizations, associations, partnerships and corporations,
whether Hospitals, health care facilities or not, from whom information has been requested by the Hospital or its
authorized representatives or who have requested such information from the Hospital and its authorized representatives.
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 10 of 19
MINDEN MEDICAL CENTER
DESIGNATION AND AUTHORIZATION FOR RELEASE (“Release”)
I further acknowledge that: (1) Medical Staff appointments at this Hospital are not a right; (2) my request will be evaluated
in accordance with prescribed procedures defined in these Bylaws and Rules & Regulations; (3) all Medical Staff
recommendations relative to my application are subject to the ultimate action of the Board whose decision shall be final; (4)
I have the responsibility to keep this application current by informing the Hospital through the CEO, of any change in the
areas of inquiry contained herein; and (5) appointment and continued clinical privileges remain contingent upon my
continued demonstration of professional competence and cooperation, my general support of the acceptable performance
of all responsibilities related thereto, as well as other factors that are relevant to the effective and efficient operation of the
Hospital. Appointment and continued clinical privileges shall be granted only on formal application, according to the
Hospital and these Bylaws and Rules & Regulations, and upon final approval of the Board.
I understand that before this application will be processed that: (1) I will be provided a copy of the Medical Staff Bylaws and
such Hospital policies and directives as are applicable to appointees to the Medical Staff, including these Bylaws and Rules &
Regulations of the Medical Staff presently in force; and (2) I must sign a statement acknowledging receipt and an
opportunity to read the copies and agreement to abide by all such bylaws, policies, directives and rules and regulations as
are in force, and as they may thereafter be amended, during the time I am appointed to the Medical Staff or exercise
clinical privileges at the Hospital.
If appointed or granted clinical privileges, I specifically agree to: (1) refrain from fee-splitting or other inducements relating
to patient referral; (2) refrain from delegating responsibility for diagnosis or care of hospitalized patient to any other
practitioner who is not qualified to undertake this responsibility or who is not adequately supervised; (3) refrain from
deceiving patients as to the identity of any practitioner providing treatment or services; (4) seek consultation whenever
necessary; (5) abide by generally recognized ethical principles applicable to my profession; (6) provide continuous care and
supervision as needed to all patients in the Hospital for whom I have responsibility; and (7) accept committee assignment
and such other duties and responsibilities as shall be assigned to me by the Board and Medical Staff.
Signature stamps and date stamps are not acceptable.
Signature:
Printed Name:
Date (DO NOT TYPE):
All applicants have the right to be informed of their application status. Application status inquiries should be
directed to Minden Medical Center. Practitioners may utilize any or all of the following to ensure accurate file
information.




The right of practitioners to review information submitted to support their credentialing application.
The right of practitioners to correct erroneous information.
The right of practitioners to be informed of the status of their credentialing or recredentialing application
upon request.
The right of practitioners to be notified of these rights.
This application has been designed to streamline the credentials verification process for providers, and meets the
standards of many accrediting organizations. The application will be processed in accordance with Minden Medical
Center’s required standards.
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 11 of 19
HOSPITAL AFFILIATIONS: ADDENDUM
Name and Mailing Address of Other Hospital/Institution:
Telephone #:
Fax#:
Department/Status (active, provisional, courtesy, consulting, temporary, etc)
Name and Mailing Address of Other Hospital/Institution:
Telephone #:
Fax#:
Department/Status (active, provisional, courtesy, consulting, temporary, etc)
Name and Mailing Address of Other Hospital/Institution:
Telephone #:
Fax#:
Department/Status (active, provisional, courtesy, consulting, temporary, etc)
Name and Mailing Address of Other Hospital/Institution:
Telephone #:
Fax#:
Department/Status (active, provisional, courtesy, consulting, temporary, etc)
Name and Mailing Address of Other Hospital/Institution:
Telephone #:
Fax#:
Department/Status (active, provisional, courtesy, consulting, temporary, etc)
Name and Mailing Address of Other Hospital/Institution:
Telephone #:
Fax#:
Department/Status (active, provisional, courtesy, consulting, temporary, etc)
Name and Mailing Address of Other Hospital/Institution:
Telephone #:
Fax#:
Department/Status (active, provisional, courtesy, consulting, temporary, etc)
City:
State:
Zip:
Appointment Dates:
City:
State:
Zip:
Appointment Dates:
City:
State:
Zip:
Appointment Dates:
City:
State:
Zip:
Appointment Dates:
City:
State:
Zip:
Appointment Dates:
City:
State:
Zip:
Appointment Dates:
City:
State:
Zip:
Appointment Dates:
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 12 of 19
We aspire to be the
finest hospital in the
country by
coordinating the
delivery of health
care services which
meet the primary
needs of our
inpatients and
outpatients in a
personalized, caring,
quality oriented, cost
effective manner.
Minden Medical Center
#1 Medical Plaza
Minden, LA 71055
Employee Health and
Education Office
318-371-3266
TB Skin Test and FIT test Record
Name: ___________________________ Dept: ________________
Date: ____________________________
TB SKIN TEST RECORD
Have you ever had a TB Skin test before?
When? _________________________
Yes
No
Result? _____________
If it was positive did you receive treatment?
Yes
No
Where did you receive treatment? ____________________________
Have you ever had a reaction to the TB Skin Test?
Have you ever received the BCG vaccination?
Yes
Yes
No
No
Signature: ___________________________________
TB TEST
Date Given: ____________
Location: _____________
Given by: ______________
Date Read: ____________
Read by: ______________
Result: ________________
Lot: __________________
CHEST X-RAY
Date Ordered: ______________
Results Rec’d: ______________
Results: ___________________
FIT MASK TEST/RECHECK
Brand: Kimberly Clark PFR95
Type: Duck Bill N-95
Size: ___ Regular ___ Small
___ Unable to fit
*_________________________
Safety Seal: ___ YES ___ NO
*Note* Employees who have a change in facial size or shape MUST return to Employee Health for N-95
ReFitting. Fit testing is an annual requirement along with TB Skin Testing and will be done with your
annual evaluation.
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 13 of 19
PROFESSIONAL LIABILITY ADDENDUM
This form must be completed if you answered “yes” to questions 1 and/or 2 on page 5
Please complete this form for each pending or settled professional liability action or any payment made on behalf of applicant. All
questions must be answered completely. If additional sheets are required, please photocopy this page prior to completing. Please
provide us with a separate sheet for each malpractice action. IF YOU HAVE NO HISTORY TO REPORT, PLEASE INDICATE THAT
AND SIGN AND DATE THE FORM.
Please Print
Date of Alleged Incident
Date Suit Filed
Location of Incident
Your relationship to patient (Attending Provider, Surgeon, Assistant Surgeon, Consultant, etc.)
Allegation
Liability Carrier when Incident Occurred
Additional named responsible parties/defendants
Claim Status
 OPEN – If open, amount being sought
 CLOSED – If closed, indicate method of closing
Amount of settlement or judgment
Summarize the circumstances surrounding claim. Please print.
SUMMARY
I certify that the information in this document and any attached documents is true, correct and complete. I agree that the facility I
am applying to and any representatives of the facility, and any individuals or entities providing information to the facility I am
making application to, in good faith and without malice shall not be liable for any act or omission related to the evaluation or
verification contained in this document, which is part of the application which I am submitting. I further agree to make notification
within 15 days of my change to the information included in this form.
Signature:
Printed Name:
Date DO NOT TYPE:
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 14 of 19
Disclosure
Minden Medical Center will obtain one or more consumer reports or investigative consumer reports (or both) about
you for employment purposes. These purposes may include hiring, contract, assignment, promotion, re-assignment,
and termination. The reports will include information about your character, general reputation, personal characteristics,
and mode of living.
We will obtain these reports through a consumer reporting agency. Our consumer reporting agency is General
Information Services, Inc. GIS’s address is P.O. Box 353, Chapin, SC 29036. GIS’s telephone number is (866) 265-4917.
GIS’s website is at www.geninfo.com.
To prepare the reports, GIS may investigate your education, work history, professional licenses and credentials,
references, address history, social security number validity, right to work, criminal record, lawsuits, driving record,
credit history, and any other information with public or private information sources.
You may inspect GIS’s files about you (in person, by mail, or by phone) by providing identification to GIS. If you do, GIS
will provide you help to understand the files, including trained personnel and an explanation of any codes. Another
person may accompany you by providing identification.
If GIS obtains any information by interview, you have the right to obtain a complete and accurate disclosure of the
scope and nature of the investigation performed.
The Federal Trade Commission provides a summary statement of your rights on its website at www.ftc.gov/credit.
Please sign below to acknowledge your receipt of this disclosure.
Signature:
Printed Name:
Date:
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 15 of 19
CONSUMER AUTHORIZATION
I. I understand that an investigative report may be generated on me that may include information as to my character, general reputation, personal characteristics, or
mode of living; work habits, performance or experience, along with reasons for termination of past employment/professional license or credentials; financial/credit
history; or criminal/civil/driving record history. I understand that General Information Services, Inc. (GIS), on behalf of LIFEPOINT HOSPITALS, INC may be requesting
information from public and private sources about any of the information noted earlier in this paragraph in connection with LIFEPOINT HOSPITALS, INC. and its
affiliates’ consideration of me for employment, promotion or position re-assignment or contract now, or at any time during my tenure with LIFEPOINT HOSPITALS,
INC. and its affiliates, and give my full consent for this information to be obtained.
II. IF APPLICABLE, medical and worker’s compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA)
and/or any other applicable state laws.
III. According to the Fair Credit Reporting Act (FCRA, Public Law 91-508, Title VI), I am entitled to know if the considerations for which I am applying are denied
because of information obtained from a consumer reporting agency. If so, I will be notified and be given the name of the agency providing that report.
IV. I acknowledge that a telephonic facsimile (FAX) or photographic copy of this release shall be as valid as the original. This release is valid for most federal, state
and county agencies.
V. I understand that if I am a resident of Minnesota/Oklahoma (only) I may obtain a copy of the report ordered, and now indicate my desire to do so by checking
this box .
VI. I hereby authorize, without reservation, any financial institution, law enforcement agency, information service bureau, school, employer or insurance company
contacted by GIS to furnish the information described in Section I.
VII. Upon proper identification, you have the right to make a request to GIS, within a reasonable period of time, as to the nature and substance of all information in its
files on you at the time of your request, including the sources of information and the recipients of any reports on you that GIS has previously furnished.
Communications with GIS should be directed to PO Box 353, Chapin SC 29036 or (866) 265-4917.
CANDIDATE COMPLETE THE FOLLOWING:
_
Signature
Today’s Date
________________________________
Please PRINT Full name
The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is
confidential and will not be used for any other purposes.
Month, Day and Year of Birth
Social Security Number
Home Address
City
Driver’s License Number and State
State
Zip
Name as it appears on License
Gender (Male/Female)
Alternate Name(s) Used
Applicant Phone Number
Alternate Applicant Phone Number
Professional License Held
License Number and State Issued
Previous Addresses for the Last 7 Years (use additional page if needed)
Street Address
City
State
Zip
Street Address
City
State
Zip
Employment to cover up to 7 years (attach additional page if needed)
May we contact your current employer?
 Yes  No
1. _____________________________________________
Employer Name
______________________________
City, State
________________________________
Phone Number
_____________________________________________
Dates: To / From
______________________________
Job Title
________________________________
Reason for Leaving
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 16 of 19
2. _____________________________________________
Employer Name
_____________________________________________
Dates: To / From
______________________________
City, State
______________________________
Job Title
________________________________
Phone Number
________________________________
Reason for Leaving
3. _____________________________________________
Employer Name
______________________________
City, State
________________________________
Phone Number
_____________________________________________
Dates: To / From
______________________________
Job Title
________________________________
Reason for Leaving
Education (List Highest Degree - use additional page if needed)
Institute Name
City, State
______________________________ Graduated?  Yes  No ______________________________ ________________________________
Dates Attended
Degree Earned – GED or Diploma Name while attending
Please provide three (3) Professional References
1. _____________________________________________
Reference Name
______________________________
City, State
________________________________
Phone Number
________________________________
Alt Phone Number (cell or other)
2. _____________________________________________
Reference Name
______________________________
City, State
________________________________
Phone Number
________________________________
Alt Phone Number (cell or other)
3. _____________________________________________
Reference Name
______________________________
City, State
________________________________
Phone Number
________________________________
Alt Phone Number (cell or other)
Have you ever been convicted of a crime? __ No __ Yes If yes, please provide offense date, city and state of conviction and details of conviction.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
NOTICE TO CALIFORNIA CANDIDATES
You have a right to obtain a copy of any consumer report or investigative consumer report obtained by LIFEPOINT HOSPITALS, INC by checking
the box provided below. The report will be provided to you within three (3) business days after we receive the requested reports related to the matter
investigated.
 I request to receive a free copy of this report by checking this box.
Under section 1786.22 of the California Civil Code, you may view the file maintained on you by GIS during normal business hours. You
may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services, by appearing at GIS in
person or by mail. You may also receive a summary of the file by telephone. The agency is required to have personnel available to
explain your file to you and the agency must explain to you any coded information appearing in your file. If you appear in person, a person
of your choice may accompany you, provided that this person furnishes proper identification.
Para informacion en espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave. N.W.,
Washington, D.C. 20580.
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 17 of 19
A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies.
There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about
check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information,
including information about additional rights, go to www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade
Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to
deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you
the name, address, and phone number of the agency that provided the information.
You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting
agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many
cases, the disclosure will be free. You are entitled to a free file disclosure if:
a person has taken adverse action against you because of information in your credit report;
you are the victim of identity theft and place a fraud alert in your file;
your file contains inaccurate information as a result of fraud;
you are on public assistance;
you are unemployed but expect to apply for employment within 60 days.
In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit
bureau and from nationwide specialty consumer reporting agencies. See www.ftc.gov/credit for additional information.
You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit
bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real
property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the
mortgage lender.
You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and
report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.ftc.gov/credit for an
explanation of dispute procedures.
Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable
information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it
has verified as accurate.
Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative
information that is more than seven years old, or bankruptcies that are more than 10 years old.
Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need–usually to consider
an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.
You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to
your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the
trucking industry. For more information, go to www.ftc.gov/credit.
You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers
for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these
offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).
You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information
to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.
Identity theft victims and active duty military personnel have additional rights. For more information, visit www.ftc.gov/credit.
States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state
law. For more information, contact your state or local consumer protection agency or your state Attorney General. Federal enforcers are:
TYPE OF BUSINESS:
CONTACT:
Consumer reporting agencies, creditors and others not listed below
Federal Trade Commission: Consumer Response Center – FCRA; Washington,
DC 20580 1-877-382-4357
National banks, federal branches/agencies of foreign banks (word
Office of the Comptroller of the Currency; Compliance Management, Mail
"National" or initials "N.A." appear in or after bank's name)
Stop 6-6; Washington, DC 20219; 800-613-6743
Federal Reserve System member banks (except national banks, and
Federal Reserve Consumer Help (FRCH); P O Box 1200; Minneapolis, MN
federal branches/agencies of foreign banks)
55480; Telephone: 888-851-1920; www.federalreserveconsumerhelp.gov;
ConsumerHelp@FederalReserve.gov
Savings associations and federally chartered savings banks (word
Office of Thrift Supervision; Consumer Complaints; Washington, DC 20552;
"Federal" or initials "F.S.B." appear in federal institution's name)
800-842-6929
Federal credit unions (words "Federal Credit Union" appear in
National Credit Union Administration; 1775 Duke Street; Alexandria, VA
institution's name)
22314; 703-519-4600
State-chartered banks that are not members of the Federal Reserve Federal Deposit Insurance Corporation; Consumer Response Center, 2345
System
Grand Avenue, Suite 100; Kansas City, Missouri 64108-2638; 877-275-3342
Air, surface, or rail common carriers regulated by former Civil
Department of Transportation; Office of Financial Management;
Aeronautics Board or Interstate Commerce Commission
Washington, DC 20590; 202-366-1306
Activities subject to the Packers and Stockyards Act, 1921
Department of Agriculture; Office of Deputy Administrator – GIPSA;
Washington, DC 20250; 202-720-7051
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 18 of 19
CHECK-LIST OF DOCUMENTS TO BE RETURNED BY APPLICANT
 Completed and signed application (and supplemental documents). The release must have
been signed within ninety (90) days. Signature stamps and date stamps are not
acceptable.
 Current curriculum vitae or resume including months and years for all places of
employment during the past fifteen (15) years. Explain any gaps of six (6) months or more
during the past five (5) years.
 Copies of: current state professional license/certificate or registration (including Board
certification/recertification, CPR, ACLS, PALS, and NRP (whatever is applicable for your
Staff Category), federal DEA registration certificate and Controlled Dangerous Substance
Registration (CDS). If your registration(s) will be expiring within the next sixty (60) days,
please provide a copy of the renewal certificate.
□
Pending
 Proof of current medical malpractice coverage that includes the effective date, amount
and type of coverage. If your coverage will be expiring within the next sixty (60) days,
please provide a copy of the renewal certificate. □ Pending
 For hospital appointments, please attach delineation of privileges.
 Copy of your driver’s license (please mail legible copy), if applying for hospital privileges
(please email a color copy in jpeg format to Shannie.gobert@lpnt.net for your hospital
ID badge).
 Copy of Social Security Card
 Copy of ECFMG Certificate, if foreign medical graduate.
 Copies of continuing medical education credits obtained during the last two (2) years.
 Current TB or Chest X-ray results.
 Any additional attachments required by the application.
Please return this information to the attention of: MMC’s Medical Staff Office
P.O. Box 5003▪Minden, LA 71058▪ (318) 371-4325 ofc▪ (318) 371-3239 fax
Page 19 of 19