MEMBERSHIP STATUS – USE FOR SECTIONS C AND D

Please use the following key to indicate membership status in sections C

(Hospital  Membership – Current  and  Pending) and D (Ambulatory Surgical

Treatment Center Practice) below.

A.

Active

F.

Active Provisional Staff

K.

Pending

B.

Courtesy

G.

Senior Staff

L.

Other (Specify)

C.

Consulting

H.

Associate

D.

Adjunct

I.

Provisional

E.

Suspended/

J.

Affiliate

Terminated/

Resigned

A.

Primary Hospital

Hospital Name:

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

To Present

From (mm/yy)

Department/Division:

Medical Staff Office FAX:

(    )

Department Telephone #:

(     )

Do you have admitting privileges at this hospital?

 Yes

 No

Any limitations in your area of specialty at this hospital?

B.

Other Hospital

Hospital Name:

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

To Present

From (mm/yy)

Department/Division:

Medical Staff Office FAX:

(    )

Department Telephone #:

(     )

Do you have admitting privileges at this hospital?

 Yes

 No

Any limitations in your area of specialty at this hospital?

C.

Other Hospital

Hospital Name:

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

To Present

From (mm/yy)

Department/Division:

Medical Staff Office FAX:

(    )

Department Telephone #:

(     )

Do you have admitting privileges at this hospital?

 Yes

 No

Any limitations in your area of specialty at this hospital?

Check here if you have appended additional information for this section

A.

Primary Ambulatory Surgical Treatment Center

ASTC Name:

Address:

Street

City

State

Zip

FAX#:

(     )

Telephone #:

(     )

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

B.

Other Ambulatory Surgical Treatment Center

ASTC Name:

Address:

Street

City

State

Zip

FAX#:

(     )

Telephone #:

(     )

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

C.

Other Ambulatory Surgical Treatment Center

ASTC Name:

Address:

Street

City

State

Zip

FAX#:

(     )

Telephone #:

(     )

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

Check here if you have appended additional information for this section.

Current work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To Present

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Check here if you have appended additional information for this section.

FIRST UPDATE

 Fellowship

 Residency

 Other

Institution Name:

Department Chair or Program Director:

Last Name

First Name

MI

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Dates attended:

From:

To:

mm/yy

mm/yy

Type of internship:

 Rotating

 Straight

If straight, please list specificaly

Did you successfully complete this program?

If no, please list specialty:

 Yes

 No

Were you the subject of any disciplinary action during your attendance at this institution?

(Attached an explanation of a "Yes" answer.)

 Yes

 No

SECOND UPDATE

 Fellowship

 Residency

 Other

Institution Name:

Department Chair and Program Director:

Last Name

First Name

MI

Degree

Mailing Address:

Street

City

State

Zip

Dates attended:

From:

To:

Mm/yy

Mm/yy

Types of internship:

 Rotating

 Straight:

If straight, please list specialty:

Did you successfully complete this program?

 Yes

 No

Were you the subject of any disciplinary action during your attendance

this institution?

 Yes

 No

(Attach an explanation of a "Yes" answer.)

Check here if you have appended additional information for this section:

1.

Has your license to practice in any jurisdiction ever been denied, restricted, limited, suspended, revoked, cancelled and/or subject to probation, either voluntarily or involuntarily, or has your application for a license ever been withdrawn?

Yes

No

2.

Have you ever been reprimanded and/or fined, been the subject of a complaint, and/or been notified in writing that you have been investigated as the possible subject of a criminal, civil or disciplinary action by any state or federal agency that licenses providers?

Yes

No

3.

Have you lost any board certifications, and/or failed to recertify?

Yes

No

4.

Have you been examined by a Certifying Board but failed to pass?

Yes

No

5.

Has any information pertaining to you, including malpractice judgements and/or disciplinary action, ever been reported to the National Practitioner Data Bank (NPDB) and/or any other practitioner data bank?

Yes

No

6.

Has your federal DEA number and/or state controlled substances license been restricted, limited, relinquished, suspended or revoked, either voluntarily or involuntarily, and/or have you ever been notified in writing that you are being investigated as the possible subject of a criminal or disciplinary action with respect to your DEA or controlled substance registration?

Yes

No

7.

Have you or any of your hospital or ambulatory surgical treatment center (ASTC) privileges and/or membership been denied, revoked, suspended, reduced, placed on probation, proctored, placed under mandatory consultation or non-renewed?

Yes

No

8.

Have you voluntarily or involuntarily relinquished or failed to seek renewal of your hospital or ASTC privileges for any reason?

Yes

No

9.

Have any disciplinary actions or proceedings been instituted against you and/or are any disciplinary actions or proceedings now pending with respect to your hospital or ASTC privileges and/or your license?

Yes

No

10.

Have you ever been reprimanded, censured, excluded, suspended and/or disqualified from participating in Medicare, Medicaid, CHAMPUS and/or any other governmental health-related programs, or voluntarily withdrawn to avoid an investigation relating to those programs?

Yes

No

11.

Have Medicare, Medicaid, CHAMPUS or PRO authorities, and/or any other third party payors, brought charges against you for alleged inappropriate fees and/or quality-of-care issues?

Yes

No

12.

Have you been denied membership and/or been subject to probation, reprimand, sanction or disciplinary action, or have you ever been notified in writing that you are being investigated as the possible subject of a criminal or disciplinary action by any health care organization, e.g., hospital, HMO, PPO, IPA, professional group or society, licensing board, certification board, PSRO, or PRO?

Yes

No

13.

Have you withdrawn an application or any portion of an application for appointment or reappointment for clinical privileges or staff appointment or for a license or membership in an IPA, PHO, professional group or society, health care entity or health care plan prior to a final decision to avoid a professional review or an adverse decision?

Yes

No

1.

Have any professional liability judgements ever been entered against you?

Yes

No

2.

Have any professional liability claim settlements ever been paid by you and/or paid on your behalf?

Yes

No

3.

Are there any currently pending professional liability suits, actions and/or claims filed against you?

Yes

No

4.

Has any person or entity ever been sued for your clinical actions?

Yes

No

Have you ever been denied or voluntarily relinquished your professional liability insurance coverage, and/or have had your professional liability insurance coverage canceled or non-renewed or limits reduced?

Yes

No

1.

Have you been charged with or convicted of a crime (other than a minor traffic offense) in this or any other  state or country and/or do you have any criminal charges pending other than minor traffic offenses in this State or any other state or country?

Yes

No

2.

Have you been the subject of a civil or criminal complaint or administrative action or been notified in writing that you are being investigated as the possible subject at a civil, criminal or administrative action regarding sexual misconduct, child abuse, domestic violence or elder abuse?

Yes

No

Do you have a medical  condition, physical defect or emotional impairment that in any way impairs and/or limits your ability to practice medicine with reasonable skill and safety?

Yes

No

CHEMICAL SUBSTANCES OR ALCOHOL ABUSE

If you answer "yes" to any questions in this section, please complete FORM F. Please make copies of FORM F, if needed, and complete one for each "yes" answer.

1.

Are you currently engaged in illegal use of any legal or illegal substances?

Yes

No

2.

Do you currently overuse and/or abuse alcohol or any other controlled substances?

Yes

No

3.

If you use alcohol and/or chemical substances, does your use in any way impair and/or limit your ability to practice medicine with reasonable skill and safety?

Yes

No

4.

Are you currently participating in a supervised rehabilitation program and/or professional assistance program that monitors you for alcohol and/or substance abuse?

Yes

No

INVESTMENTS

In the last 5 years have you and/or a member of your family purchased or made an investment in (other than securities of a publicly traded company), or otherwise have a business interest in any clinical laboratory, diagnostic or testing center, hospital, surgicenter, and/or other business dealing with the provision of ancillary health services, equipment or supplies?

Yes

No

If "yes", please provide explanation:

Primary Site

Group/Business Name

Building Name

Office Address – Number and Street – Suite

City

County

State

Zip

(     )

Main Telephone Number

Office Administrator –

Last

First

MI

(     )

(     )

Beeper Number

Fax Number

E-Mail

(     )

(     )

Emergency Number

Answering Service

Are you currently accepting new patients at this location?  Yes  No

If "yes", describe any restrictions (e.g., appointment type, patient type):

Please provide the number of active patients enrolled with you at this site:

Please provide the number of patient visits you have at this site per year:

List any special skills or qualifications you or your office staff have that enhance your ability to practice medicine or treat certain patients or classes of patients. List separately any special language skills, such as fluency in a foreign language or proficiency in sign language.

Special Skills of Practitioner:

Special Skills of Staff:

Languages Spoken by Practitioner:

Languages Written by Practioner:

Languages Spoken by Staff:

Languages Written by Staff:

Please provide the following information about physicians/practitioners who provide coverage for patients enrolled at this site when you are not available.

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(     )

Street

City

State

Zip

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(     )

Street

City

State

Zip

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(     )

Street

City

State

Zip

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Primary Site

Group/Business Name

Building Name

Office Address – Number and Street – Suite

City

County

State

Zip

(     )

Main Telephone Number

Office Administrator –

Last

First

MI

(     )

(     )

Beeper Number

Fax Number

E-Mail

(     )

(     )

Emergency Number

Answering Service

Are you currently accepting new patients at this location?  Yes  No

If "yes", describe any restrictions (e.g., appointment type, patient type):

Please provide the number of active patients enrolled with you at this site:

Please provide the number of patient visits you have at this site per year:

List any special skills or qualifications you or your office staff have that enhance your ability to practice medicine or treat certain patients or classes of patients. List separately any special language skills, such as fluency in a foreign language or proficiency in sign language.

Special Skills of Practitioner:

Special Skills of Staff:

Languages Spoken by Practitioner:

Languages Written by Practitioner:

Languages Spoken by Staff:

Languages Written by Staff:

Please provide the following information about physicians/practitioners who provide coverage for patients enrolled at this site when you are not available.

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(     )

Street

City

State

Zip

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(     )

Street

City

State

Zip

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(     )

Street

City

State

Zip

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

End Recredentialing and Business Data Gathering Form.

Attach Forms A-F As Required.

Last

First

MI

Indicate the number of ONE of the questions in Section I to which you  answered "yes":

Question Number:

A.

Describe the circumstances surrounding this occurrence. Please include the date of the occurrence.

B.

Provide an explanation of any actions taken. Please include the date the action was taken.

C.

Provide the current status of the issue.

D.

If known:

Contact

Department/Committee:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Signature:

Date:

Applicant Name:

Last

First

MI

A.

Plaintiff’s Name:

Last

First

MI

If court case, Case Name & Case Number:

B.

Your Involvement in the Care (Attending, Consulting, Etc.)

C.

Your Status in the Case (Sole Defendant, Co-Defendant, Ownership Interest in

Provider Practice Named in Suit, Etc.)

D.

Allegations, including Patient Outcome, If Available:

E.

Date of Incident (mm/yy)

F.

Date Filed (mm/yy)

G.

Date Case Closed (mm/yy):

Case Resolution:

Dismissed

Judgement

Arbitration

Other

Settlement Out of Court

Pending

Mediation

H.

Amount Paid on Your Behalf (if any): $

I.

Professional Liability Insurer Name (if one was involved):

J.

Insurer Telephone Number:

(        )

K.

Policy Number:

L.

Insurer Address (Street, City, State, Zip Code):

Signature:

Date:

Applicant Name:

Last

First

MI

A.

History of Professional Liability Insurance (Please Check One)

Cancelled Voluntarily

    Non-Renewed

Cancelled Involuntarily

    Application Denied

B.

Carrier Name:

C.

Carrier Telephone Number:

(     )

D.

Policy Number:

E.

Carrier Address:

Street

City

State

Zip

F.

Dates of Coverage:

From (mm/yy):

To (mm/yy):

G.

Circumstances Involved:

Signature:

Date:

Applicant Name:

Last

First

MI

A.

Date of Incident (mm/yy):

B.

Date of Complaint or Conviction (mm/yy):

C.

Date of Resolution (mm/yy):

D.

Type of Resolution (Dismissed, Plea Bargain, Misdemeanor, Felony):

E.

Allegations:

F.

Details of Incident:

G.

Actions Taken Against You:

H.

Current Status of Situation:

I.

Medical Practice Privileges Affected as a Result of This Situation:

Signature:

Date:

Applicant Name:

Last

First

MI

A.

Describe this medical condition:

B.

To what extent does or could this condition affect your current ability to practice

medicine in your specialty area or to perform a full range of clinical activities?

C.

What is the current status of your condition?

D.

Provide the name and address of your personal physician/health care provider who can provide information about your health condition.

Name

Telephone Number

(     )

Last

First

MI

Degree

(     )

Last

First

MI

Degree

Signature:

Date:

Applicant Name:

Last

First

MI

Describe the substance you use:

A.

To what extent does, or could, your use of this substance affect your current ability to practice medicine in your specialty area or to perform a full range of clinical activities?

B.

Monitored by State Board Mandate (Name and Address)

C.

Monitored Voluntarily (Name and Address)

D.

Other information about the current status of your use of substances:

E.

Abstinent since (mm/yy):

F.

Provide the name and address of your personal physician/health care provider who can provide information about your treatment for alcohol or chemical substance use and can comment on what impact (if any) it has on your current/future professional practice.

Name:

Last

First

MI

Degree

Address:

Street

City

State

Zip

Telephone Number:

(     )

Signature:

Date: