Anderson Hospital · Anderson Hospital 6800 State Route 162 Maryville, Illinois 62062...
Transcript of Anderson Hospital · Anderson Hospital 6800 State Route 162 Maryville, Illinois 62062...
Anderson Hospital 6800 State Route 162
Maryville, Illinois 62062 [email protected]
Re: Application Documentation
Dear Provider,
Enclosed please find the State of Illinois Health Care Professional Credentialing and Business Data Gathering Form. This is a State Mandated form and must be received in order to apply for membership and/or privileges at Anderson Hospital. Your application will be processed in accordance with the Medical Staff Bylaws, Rules and Regulations.
PLEASE MAKE SURE TO COMPLETE THE CORRECT FORM – CREDENTIALING VS. RECREDENTIALING. If a section or question does not apply to you, then mark "N/A". Please make sure every line and or box is completed. This includes the additional Form A – F that must be completed if any questions are answered "yes" on pages 19-21. If there are any blanks, the application will be considered incomplete and the form will be returned to you for completion.
In addition to the State of Illinois Mandated form, we are also requesting completion of facility specific documents. These are:
Anderson Hospital Supplemental Information Form NOTE: the last page of this form requests the staff category you are applying for – please read the attached category sheet and determine which category best suits your needs. All Active members will be placed on a committee meeting assignment. If you wish to request Membership only – please indicate.
Anderson Hospital – Applicant’s Attestation Anderson Hospital – Medical Staff member Consent and Release Anderson Hospital – Health Statement NOTE: Please sign the form at the top and forward to
your private physician.
MHA Background Check Request Form – this form MUST be completed in order for the Medical Staff Office to run a required Health Care background check. We cannot run a check without ALL of the information requested in the top section (complete every box from ‘name’ through ‘date’). The bottom is for our use only. Any forms returned with the required information missing will be returned.
Anderson Hospital Conflict of Interest Agreement – This form must be completed – if you have no conflicts then please indicate this in the area provided.
Delineation of Privileges Form – Please check the privileges requested and provide proof of competency by submitting your case logs for the past 12 months. If the form is not checked and the logs are not received with the application – it will be deemed incomplete.
AutoFaxing Enrollment Form – if you wish to receive faxed reports automatically Notice to Physicians, regarding Champus, Medicare, Medicaid – REQUIRED Signature Card Provider Contact Information Professional/Peer Reference Forms (Please send to at least three references)
It is the obligation of the applicant to provide information on the matters listed in the application to the satisfaction of the hospital. An application must be completed within ninety (90) days. Time begins upon our receipt of the completed application. This time frame also includes the hospital verification process required for our application procedure – this process will go faster if full address, fax numbers and/or emails are supplied. An application will not be presented to the Credentials Committee until it is Complete.
Failure to provide all information listed above within the above stated time frame shall be construed as withdrawal of the application.
A checklist is enclosed to assist you in completing your application packet. The checklist includes instructions for completion of the state mandated form, lists additional forms to be that must accompany your application to deem your application complete.
We look forward to receiving your completed application. If you have any questions, please feel free to contact the Medical Staff Office at 618-391-6140 or the email above. Thank you for your interest in Anderson Hospital.
Sincerely,
V{Ü|áàÉÑ{xÜ YtÜÜtÜ? `W Christopher Farrar, MD – President Elect Chairman of the Credentials Committee
6800 State Route 162 Maryville, Illinois 62062
618-391-6140 618-391-6141618-288-2164 FAX
Page 1 of 2
APPLICATION CHECKLIST Instructions for Completing State Mandated Form - Please read carefully
1. Chapter A: Practice & Professional Information
A. Section A. General Information If something does not apply to you – please fill in the blank with N/A Social Security Number and Full Address (including zip code) does apply
B. Section B. Professional Information Copies of ALL current licenses in all states must accompany your application
C. Section C. Professional Liability Insurance The State of Illinois requires that applicants go back 10 years or to residency. Attach a current Malpractice certificate with Anderson Hospital as the certificate holder on the policy.
D. Section D. Education & Training Addresses must be complete and current. If a letter is returned – the applicant is responsible to get the
correct address to Anderson Hospital for verification purposes. Fax numbers and emails may also beprovided. Dates must also be provided
E. Section E. Hospital Membership - Current & Pending Addresses must be complete and current. If a letter is returned – the applicant is responsible to get the
correct address to Anderson Hospital for verification purposes. Fax numbers and emails may also beprovided. Dates must also be provided
F. Section F. Hospital Membership – Previous Addresses must be complete and current. If a letter is returned – the applicant is responsible to get the
correct address to Anderson Hospital for verification purposes. Fax numbers and emails may also beprovided. Dates must also be provided
G. Section G. Ambulatory Surgery Center Practice Addresses must be complete and current. If a letter is returned – the applicant is responsible to get the
correct address to Anderson Hospital for verification purposes. Fax numbers and emails may also beprovided. Dates must also be provided
H. Section H. Work History Addresses must be complete and current. If a letter is returned – the applicant is responsible to get the
correct address to Anderson Hospital for verification purposes. Fax numbers and emails may also beprovided. Dates must also be provided
I. Section I. Professional References Addresses must be complete and current. If a letter is returned – the applicant is responsible to get the
correct address to Anderson Hospital for verification purposes. Fax numbers and emails may also beprovided. Dates must also be provided
J. Section J. Professional History: Confidential - complete all portions except Investments
2. Chapter B: Business Information
A. Section K. Primary Site Information - complete only through the phone and fax numbersB. Section M. Additional Site Information - complete only through the phone and fax numbers
3. Attach Forms A - F as required.
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Along with your completed application, you MUST provide the following:
1. Copy of your insurance Declaration page which includes your insurance class, exceptions, additions, etc. 2. Copy of your Illinois Controlled Substance license 3. Copy of your Federal Drug Enforcement Administration license 4. Copy of your diploma from your medical school 5. Evidence of Board Certification - copy of certificate 6. Copy of your CV/Resume 7. Clear Photo of you to be used for identification purposes 8. Application fee of $400 for physicians; $150 for Allied Health Professionals - Please make checks
payable to Anderson Hospital. No cash or credit cards will be accepted.
6800 State Route 162
Maryville, Illinois 62062 618-391-6140 618-391-6141
618-288-2164 FAX [email protected]
INVOICE
Application Fee – _______________________________ $ 400.00 (Physicians) (Print name) $ 150.00 (Allied Health Professionals)
Please submit a check made payable to Anderson Hospital – The check MUST accompany the Application to deem the application complete.
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6800 State Route 162
Maryville, Illinois 62062 618-391-6140 618-391-6141
618-288-2164 FAX [email protected]
SUPPLEMENTAL INFORMATION
Name: ___________________________________
Home Address ______________________________________________________________________________________
____________________________________________________________________________________
Home Phone _______________________________________________________________________________________ Marital Status (optional) _______________________________________________________________________________
Name of Significant Other (optional) _____________________________________________________________________
1. Name(s) of physician(s) on staff at Anderson Hospital, with the same specialty as yours, who will provide coverage. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
2. Has your present professional liability insurance carrier excluded any specific area of practice from your insurance coverage?
Yes _______ No _______ If yes, explain ________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________
3. Have any professional liability suits ever been filed against you?
Yes _______ No _______ If yes, explain _______________________________________________________________________________________ ___________________________________________________________________________________________________ ____________________________________________________________________________________________________ 4. Are there currently any pending or final judgments or settlements against you in regards to professional medical liability
action? Yes _______ No _______
If yes, explain ________________________________________________________________________________________ ____________________________________________________________________________________________________
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5. Has your medical staff membership, staff category, scope of clinical privileges, or employment ever been voluntarily or involuntarily changed or terminated at any hospital or other institution?
Yes _______ No _______
If yes, explain _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________
6. Have your clinical privileges ever been voluntarily or involuntarily limited or reduced, or have you ever had a voluntary or
involuntary loss of clinical privileges at another hospital or other facility? Yes _______ No _______
If yes, explain _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________
7. Are there currently any actions ongoing which could result in the suspension, loss or restriction of Medical Staff
membership or clinical privileges? Yes _______ No _______
If yes, explain _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________
8. If you resigned from a facility, were there any disciplinary actions or investigations in process at that time?
Yes _______ No _______
If yes, explain _____________________________________________________________________________________________ _____________________________________________________________________________________________ 9. Have you ever had any voluntary or involuntary suspension or non-renewal of Medical Staff membership or clinical
privileges?
Yes _______ No _______ If yes, explain _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________
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10. Have you ever been asked to surrender your license? Yes _______ No _______ If yes, explain ________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________
11. Have you ever been suspended, sanctioned or otherwise restricted from participating in any private, federal, or state health insurance program (for example, Medicare, Medicaid)?
Yes _______ No _______
If yes, explain ________________________________________________________________________________________ ____________________________________________________________________________________________________ _____________________________________________________________________________________________________
12. Have you ever been the subject of an investigation by any private agency concerning your participation in any private health
insurance program? Yes _______ No _______
If yes, explain _________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 13. Have there been any previously successful or are there any currently pending challenges to any licensure or registration
(state or district, DEA) or the voluntary relinquishment of such licensure or registration? Yes _______ No _______
If yes, explain _________________________________________________________________________________________ _____________________________________________________________________________________________________ ______________________________________________________________________________________________________
14. **Indicate the staff category you desire. Please see attached medical staff listing for reference.**
Active Courtesy
Active with Membership Only (No Privileges) Consulting
Associate Membership Only (No Privileges)
Affiliate
Anderson Hospital Medical Staff Status Description
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ACTIVE MEDICAL STAFF STATUS: Shall be those physicians, either resident or maintaining offices within the Hospital’s service area or a reasonable
distance therefrom, who have been selected to admit and attend patients in the Hospital. Must attend Medical Staff meetings (unless excused by the Medical Executive Committee or having attained the age of
sixty (60) years of age). Will serve upon not fewer than one of the Medical Staff’s standing committees. May vote on all Medical Staff business, hold Medical Staff offices and serve on Medical Staff Committees. Required to participate on the rotating list for emergency coverage. (Not required for age sixty (60) and older) After the first year, Active Staff members must admit or perform procedures on not fewer than twenty-four
(24) patients each reappointment cycle and/or attend not fewer than 24 patients admitted by other physicians.
Members of the Active Medical Staff, who fail to meet the requirements for membership on the Active Medical Staff, will be assigned to the Associate Medical Staff.
ACTIVE STAFF WITH MEMBERSHIP ONLY MEDICAL STAFF STATUS: Shall be those physicians, either resident or maintaining offices within the Hospital’s service area or a reasonable
distance therefrom, who utilize hospitalists for admissions and treatment of inpatients and actively use Hospital services, but wish to be active in the business of the Medical Staff.
Will attend not fewer than one Medical Staff standing committee. May vote on all Medical Staff business, hold Medical Staff offices, and serve on Medical Staff Committees. Required to participate on the rotating list for emergency coverage. (Not required for age sixty (60) and older) Members will refer not fewer than twenty-four (24) patients to hospital services each reappointment cycle. Members of the Active Staff with Membership Only who fail to attend required meetings, will be assigned to the
Membership Only staff. NO HOSPITAL PRIVILEGES. ASSOCIATE MEDICAL STAFF STATUS: Shall consist of physicians who do not wish to actively participate in the work of the Medical Staff. In certain instances,
Associate Medical Staff may be asked to participate in peer review. May attend General Staff and meetings of the clinical departments and committees. May not vote on any Medical Staff business, hold office, or chair any Medical Staff committee. Required to participate on the rotating list for emergency coverage. (Not required for age sixty (60) and older) After the first year of appointment, they shall admit or perform procedures on not fewer than twenty-four (24)
patients each reappointment cycle. Members of the Associate Medical Staff, who fail to meet the requirements for membership on the Associate Medical Staff,
will be assigned to the Courtesy Medical Staff. COURTESY MEDICAL STAFF STATUS: Shall consist of those members of the medical profession who are eligible as herein provided for Medical Staff
membership, who wish to admit private patients to the Hospital, but who do not wish to become members of the Active Medical Staff.
Members are not required to attend Medical Staff meetings. May not vote on any Medical Staff business, hold Medical Staff office or serve on Medical Staff committees. May not admit or perform procedures on more than twenty-four (24) patients each reappointment cycle. Physicians admitting or performing procedures on more than 24 patients shall be advanced to another Medical Staff
category. CONSULTING MEDICAL STAFF STATUS: Shall consist of physicians of recognized unique professional ability or specialty who are active in the Hospital or who
have signified a willingness to accept such appointment. Duties shall be to render their services upon request of any member of the Medical Staff.
Members are not required to attend meetings. May not vote on any Medical Staff business, hold Medical Staff office or serve on Medical Staff committees. May not admit or perform procedures.
Anderson Hospital Medical Staff Status Description
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AFFILIATE MEDICAL STAFF STATUS: Shall consist of physicians who are on staff at Anderson Hospital whose primary purpose is to provide coverage for
Active and Associate Medical Staff members. Duties shall be to provide coverage for his/her associate(s) as needed. Members are not required to attend meetings. Members may not vote on any Medical Staff business, hold Medical Staff office or serve on Medical Staff committees. No required volume. MEMBERSHIP ONLY MEDICAL STAFF STATUS: Shall be those physicians, either resident or maintaining offices within the Hospital’s service area or a reasonable
distance therefrom, who utilize hospitalists for admissions and treatment of inpatients and utilize the hospital services and wish to be affiliated with the Medical Staff but not active in the business of the Medical Staff.
Members are not required to attend meetings. May not vote on any Medical Staff business, hold Medical Staff office or serve on Medical Staff committees. NO HOSPITAL PRIVILEGES.
HONORARY MEDICAL STAFF STATUS: Shall consist of physicians who are not active in the Hospital and who are honored by emeritus positions. These may be: 1) Physicians who have retired from active Hospital service;
or 2) Physicians of outstanding reputation not necessarily residing in the community. Shall not vote or hold office and may not have assigned duties. Shall not admit patients. NO HOSPITAL PRIVILEGES.
6800 State Route 162
Maryville, Illinois 62062 618-391-6140 618-391-6141
618-288-2164 FAX [email protected]
ATTESTATION I hereby apply for medical staff appointment and clinical privileges as requested in this application. I am willing to make myself available for interviews in regard to this application. As a applicant, I have the burden of producing adequate information for proper evaluation of this Application. I agree to provide Anderson Hospital with updated current information regarding all questions on this application as such information becomes available and such additional information as may be requested by Anderson Hospital or its Authorized Representatives. I represent that the information given in or attached to this application is accurate and fairly represents that current level of my training, experience, capability and competence to practice. I REALIZE AND AGREE THAT ANY MISREPRESENTATION, SIGNIFICANT MISSTATEMENT OR OMISSION IN THIS APPLICATION SHALL CONSTITUTE GROUNDS FOR DENIAL OF APPOINTMENT OR TERMINATION OF ANY CLINICAL PRIVILEGES GRANTED. I understand that this application will be considered in accordance with the By-laws, Rules and Regulations of the Medical Staff of Anderson Hospital, and agree to be bound by those By-laws, Rules and Regulations. I understand that I have the burden of establishing my eligibility and competence. By applying for appointment and clinical privileges, I accept that I have the responsibility to keep this application current by informing the hospital, through the Chief Executive Officer or his designee. I understand I am obligated to notify the hospital, through the Chief Executive Officer or his designee, immediately for professional license revocation, federal Drug Enforcement Agency license revocation, or any lapse in professional liability coverage. I further understand I must notify the hospital, as noted above, within in 5 days of any corrections, updates, and modifications for Medicare or Medicaid sanctions, revocation of any hospital privileges, or conviction of a felony, and within 45 days for any other change in information from the date the health care professional knew of the change. All updates should be made on the Healthcare Professional Data Gathering form, which is mandated by the state of Illinois. I have received and had an opportunity to read a copy of Article IX of the By-Laws, Southwestern Illinois Health Facilities, Inc., and the Medical Staff By-Laws and I will receive a copy of policies upon my appointment. I specifically agree to abide by all such By-Laws, policies, directives, Rules and Regulations as are in force during the time I am appointed to the Medical Staff or exercise clinical privileges at Anderson Hospital. I agree to abide by all of the ethical principles established by the national association of my profession. I agree not to receive from or pay to any other physician, either directly or indirectly, any part of any fee paid for professional services. I agree to provide continuous care and supervision for all of my patients at Anderson Hospital.
________ ____ Date Applicant’s Signature Applicant’s Printed Name
6800 State Route 162
Maryville, Illinois 62062 618-391-6140 618-391-6141
618-288-2164 FAX [email protected]
MEDICAL STAFF MEMBER CONSENT TO RELEASE I extend absolute immunity to, and release from any and all liability, Anderson Hospital, its Medical Staff, its Authorized Representatives, and any Third Parties, all as defined below, for any acts, communications, statements, recommendations or disclosures performed in good faith and without malice, including otherwise privileged or confidential information, relating to or in connection with this Application or the consideration of the privileges sought herein. I specifically authorize Anderson 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 initial and continued appointment to the Medical Staff, and to inspect or obtain copies of any and all communications, reports, records, statements or documents from Third Parties relating to such matters. I also specifically authorize said Third Parties to disclose and release any such information to Anderson Hospital and its Authorized Representatives upon request. Any and all information received from Third Parties shall be confidential and shall not be released to the Applicant. I further authorize and consent to the release of information and records concerning me by Anderson Hospital to other hospitals, medical associations, governmental agencies or other bodies concerned with professional competency, medical malpractice or practitioner licensing, and I hereby release from liability Anderson Hospital and its Authorized Representatives for so doing. The Term “ Authorize Representatives” means Anderson Hospital and any of the following individuals who have any responsibility of obtaining or evaluating my credentials, or acting upon my Application or conduct in Anderson Hospital: The members of Anderson Hospital’s Board of Trustees and their appointed representatives; the members and officers of the Medical Staff of Anderson Hospital; the President of Anderson Hospital or his designees; other hospital employees; consultants to the hospital and the hospital’s attorneys. The term “ Third Parties” means all individuals and entities, including but not limited to physicians, health practitioners, hospitals, government agencies, associations, partnerships and corporations, from whom information concerning me or this Application has been or is requested by Anderson Hospital or its Authorized Representatives, or who have requested such information form Anderson Hospital or its Authorized Representatives. _____________________ ____________________________________________ Date Applicant’s Signature ____________________________________________ Applicant's Printed Name
HEALTH STATEMENT
To be completed by the applicant: Do you have a physical or mental condition which could affect your ability to exercise the clinical privileges requested or would require an accommodation in order for you to exercise the privileges safely and competently?
Yes No
Applicant’s Name (Please print) Applicant's Signature Date Regardless of how the above question is answered, the reapplication will be processed in the usual manner. If you have answered this question affirmatively 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 an appropriate committee to determine what accommodations are necessary or feasible to allow you to practice safely. To be completed by your Primary Care Physician (PCP): I do hereby certify that provider listed above is in good physical and mental health to carry out the duties necessary in the performance of his/her profession. Any limitations or restrictions placed on this healthcare provider are as follows: Comments: Primary Care Physician (please print) Date
Primary Care Physician Signature
AUTHORIZATION FORM ̶̶ www.backgroundcheckadvantage.com 8/23/2016
Anderson Hospital Brittany Mersinger, RHIT
618‐391‐6140
First Name Middle Name Last Name
Alias/Maiden Name(s) Will Employee's Salary Exceed $75,000?
No Yes
Social Security Number Date of Birth Race Gender
Male Female
Mailing Address (NO P.O. Boxes) City State Zip
As part of the employment volunteer student credentialing process, I consent to the release of my criminal background records and motor vehicle driving records or any search listed below by any and all states or agencies holding such records. I also agree to an investigation and the obtaining of a consumer report solely for employment volunteer student credentialing purposes. By signing this consent, I acknowledge I have received in writing a Disclosure Regarding Procurement of a Consumer Report. I understand that the Company named above may use this consent on multiple occasions to request such consumer reports. This consent will remain effective until I have affirmatively revoked it.
Signature of Applicant Date: ________ /________ /________
BACKGROUND SEARCHES
OIG (Medicare/Medicaid Fraud & Abuse) GSA (Federal Procurement Fraud) **FCSR
SSN Plus (Address & Alias Name are included) Address Verification Alias Name Search
Government Watch List (includes DOC Entity List & Denied Persons List, DOT Specially Designated Nationals & Blocked Persons List, DOS Proliferation List & more)
Wants & Warrants (Nationwide ‐ extraditable only) OFAC (Specially Designated Nationals and Blocked Persons List)
Child Abuse/Neglect – IL** IA** IN** KS** MO* NE** TN Adult Abuse/Neglect – KS
*MO Mental Health Employee Disqualification Registry MO EDL (Employee Disqualification List)
FEDERAL COURTS ‐ Criminal State 1: _______ 2: _______ SEX OFFENDER Nationwide or State 1: _________
DRIVING RECORD State _________ DL# __________________________________________________
PROFESSIONAL LICENSE National or State _________ Type: _________________________________________________ License #: _______________________________________________
EDUCATION School Name (include campus): ________________________________________________________________________
City/State: _____________________ /______ Major: _________________________________ Graduation Date: ____ /___________
Degree Type: ____________ (BSN, B.A., etc.) Name While Attending: ____________________________________________________ If additional Verifications are needed, refer to application during data entry or document on another Background Check Request Form.
CHARACTER REFERENCE PERSONAL PROFESSIONAL: Name ________________________________ Phone: _____ /______‐_______ EMPLOYMENT Company: ________________________________________________ City/State: _____________________ /_____
Phone: _____ /______‐_______ Manager: ________________________________ Start Date: ___ /______ End Date: ___ /______
Title: _________________________________________________ Starting Wage:$_______________ Ending Wage:$_____________Duties: ________________________________________________________________________________________________________
Reason for Leaving: ______________________________________________________________________________________________ If additional Verifications are needed, refer to application during data entry or document on another Background Check Request Form.
LIST CITY/COUNTY CRIMINAL SEARCHES NEEDEDStates with county by county access only: CA, LA, MA, WV and WY
County 1:_________________State: ______ County 2:_________________State: ______ County 3:_________________State: ______
STATEWIDE CRIMINAL ‐ A Statewide/State Repository houses records from all jurisdictions throughout the State
AL* AK* AZ AR* CO CT* DE DC* FL GA* HI ID** IN IA* KS KY ME MD MI MN MO MS* MT NE NV* NH** NJ NM* NY* NC* ND OH* OK OR* PA RI* SC SD TN TX UT* VA* VT* WA WI Note: Nevada & Ohio are Felony Only
Illinois Healthcare‐compliance with IL Healthcare Worker Background Check Act (IL Police Full‐State Repository Criminal) International Criminal _______________________________________________
MO‐includes MO Sex Offender results at no additional cost (MO State Highway Patrol Full‐State Repository Criminal search)
*Required Form(s) & **Required Special Form(s) must be ATTACHED when ordering or faxed to 573‐893‐7669
6800 State Route 162 Maryville, IL 62062
Phone: 618-391-6141 Fax: 618-288-2164
Provider Contact Information Please provide your contact numbers below, in order of preference, for the floors to contact you.
NAME:
CONTACT NUMBER
IN ORDER OF PREFERENCE
TYPE OF NUMBER
SPECIAL INSTRUCTIONS
1.
CELL HOME
PAGER OFFICE
EXCHANGE
2.
CELL HOME
PAGER OFFICE
EXCHANGE
3.
CELL HOME
PAGER OFFICE
EXCHANGE
4.
CELL HOME
PAGER OFFICE
EXCHANGE
5.
CELL HOME
PAGER OFFICE
EXCHANGE
Contact Number for E-prescribing clarification
CELL HOME
PAGER OFFICE
EXCHANGE
PRIMARY OFFICE ADDRESS: (PLEASE NOTE: THIS IS THE ADDRESS MEDICAL RECORD REPORTS WILL BE MAILED TO, IF APPLICABLE) OFFICE#: FAX #: EMAIL ADDRESS:
Provider Signature: ___________________________________ Date: __________________
6800 State Route 162
Maryville, Illinois 62062 618-391-6140 618-391-6141
618-288-2164 FAX [email protected]
Dear Provider: Please sign the above card exactly as you sign your medical records. As well, please initial exactly as you initial progress notes, etc. This signature card is kept on the nursing unit for reference purposes. Please return the signed and initialed form with your packet to the Anderson Hospital Medical Staff Office.
Thank you for your cooperation in this matter.
PLEASE DO NOT USE TYPED TEXT OR DOCUSIGN.
MUST BE IN BLUE OR BLACK INK.
PROVIDER SIGNATURE CARD
Printed Name: _______________________ Date: ____________
Sign your full name as it would be documented in the Medical Record:
________________________________________________________
Sign your initials as it would be documented in the Medical Record:
________________________________________________________
Anderson Conflict of Interest Agreement
I agree to avoid all actual and perceived conflicts of interest and shall abide by the Conflict of Interest –Medical Staff Allied Health Staff and Workforce Policy. I understand that a conflict of interest arises when there is a conflict between one’s personal stake in a matter and his/her fiduciary responsibility to Anderson caused by a financial interest, position, activity or other relationship with a third party. I understand it is not possible to list all types of conflicts of interests, but agree that the following general principles are areas to consider as potential conflicts and agree to avoid them:
►Products and services are to be bought and sold based solely on their value and merit. If I am involved in purchasing goods or pricing services I may not give, receive, offer or solicit any personal gifts or favors or any payment in the nature of a bribe or kickback that influences or might appear to influence purchase and pricing decisions. ►Any outside activity, such as a second job or a significant interest in another business, shall not involve any personal interest that could affect my independent judgment with my duties or discredit or embarrass Anderson. ►I or my immediate family may not have any personal interest in any sale or purchase of property by Anderson. ►I may not convey Anderson property or proprietary or confidential information or provide unpaid services to a member of the public or to an employee or agent unless approved in writing by a member of senior management/Chairman of the Board of Trustees, as appropriate. ►I shall disclose all possible conflicts of interest when those interests may affect or be perceived as affecting a decision on a proposed Anderson transaction or arrangement.
I may not enter into any agreement or arrangement that calls for a commission, rebate, consultant or service fee, bribe, kickback or should suspect from the surrounding circumstances or after a good faith inquiry, that the intent or probable results is to reward improperly, either directly or indirectly including:
►Any employee or official or other representative of any government or governmental agency or entity (including the military). ►Any officer, director, trustee, employee, shareholder or other representative of an institution with which Anderson has an existing or prospective business relationship.
►Any officer, official, member or other representative of a union. I will not give inducement to such individuals to take action favorable to Anderson or myself. The concept of an improper reward includes the giving of anything of value. Examples such as free or special price services or trips at Anderson’s expense, without a proper business purpose, may constitute an improper payment just as readily as a cash payment. No action that would otherwise be
suspect shall be permissible merely because it appears to be customary in a particular location or particular area of business activity. I understand that the practices of write‐offs, discounting and forgiveness of debt shall be subject to interpretation as gifts, inducements or even bribes. I understand that requests for special billing or payment procedures that suggest possible violations of law such as evasion of income tax, currency exchange controls or price, profit controls are contrary to policy and no such billing, or payment procedures shall be used. Such practices can also result in false, artificial or misleading entries in the books or records of Anderson and are prohibited. I understand that I am subject to termination of my position if it is determined that I have violated this agreement. I understand that I should disclose any situation that may potentially result in a conflict of interest so as to permit an impartial and objective determination. Please answer the following questions: 1. Do you have another job?
□ Yes: Include name of employer and job title: ______________________________________
□ No
2. Do you work or consult for a healthcare vendor who sells medical products or services?
□ Yes: Include Name of healthcare vendor and job duties:______________________________
□ No 3. Do you, your spouse, mother/father; grandparents; brothers/sisters; adult children have full or partial financial ownership in a healthcare/healthcare related business?
□ Yes: Include name of the business and list family member(s) who have full or partial financial
ownership: __________________________________________________________________
□ No
4. □ After reading this form, do you have any other information to disclose which you believe might
create or possibly give the perception of a conflict of interest?
□ Yes: please describe: __________________________________________________________
□ No Comments: ____________________________________________________________________________________ ___________________________________________ ___________________________ Signature Date ___________________________________________ ___________________________ Printed Name Position/Title
***SEND DIRECTLY TO YOUR MALPRACTICE INSURANCE CARRIER***
STATEMENT OF AUTHORIZATION AND RELEASE FROM LIABILITY TO MEDICAL LIABILITY PROVIDER
(Name and address of Insurance Entity) Re: Policy# I, , am applying for appointment to the Medical Staff of Anderson Hospital and hereby authorize my carrier to release to the hospital all information regarding my claims history occurring from ******* to present, but not necessarily limited to:
1. Judgments entered 2. Claims settled, and 3. Cases and lawsuits pending
Please return this information to Anderson Hospital
6800 State Route 162, Maryville, IL 62062. ATTENTION: Medical Staff Services, or FAX to (618) 288-2164
EMAIL: [email protected] 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 my application for reappointment to Anderson Hospital’s Medical Staff. Provider Signature Date
TO: The Medical Staff of Anderson Hospital, Maryville, Illinois requires each Medical Staff appointee and applicant to provide evidence of medical professional liability insurance coverage in the exact amounts of coverage per occurrence and per annual aggregate. Please send a Certificate of Medical Liability Insurance or other documentation to Anderson Hospital verifying the class of my insurance, the exact limits of the coverage I have with your company, and claims history. I also authorize Anderson Hospital to verify specific privileges covered under my policy as well as any limitations of my coverage. If available, we have attached a copy of the policy for your convenience. Please identify Anderson Hospital as the certificate holder on my policy.
________________________________ _______________________ Signature Date ________________________________ Printed Name
Office Address City State Zip
Home Address City State Zip
6800 State Route 162 Maryville, Illinois 62062
618-391-6140 618-391-6141618-288-2164 FAX
PHYSICIAN ACKNOWLEDGEMENT STATEMENT
Notice to Physicians:
Medicare, Medicaid, and Champus payment to hospital is based in part on each patient’s principal and secondary diagnoses and the major procedure 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 this essential information required for payment of Federal funds, may be subject to fine, imprisonment, or civil penalty under applicable Federal laws.
-------------------------------------------------------------------------------------------------
I acknowledge that I have received and read the above “NOTICE TO PHYSICIANS” concerning Medicare, Medicaid and Champus payment to hospitals and the penalties as stated.
_________________ Date
__________________________________ Physician Signature
__________________________________Physician's Printed Name
AUTOFAXINGENROLLMENTFORM
RequesttoEnroll RequesttoRevise
Theautofaxservicecanbeutilizedtoprovideyourofficewithimmediatefaxedreceiptofvariousmedicalreports. Pleaseindicatewhetheryouwishtoreceivereportsfromoneormoreofthefollowingreportcategories:
**RadiologyReports _____AutofaxOR ______PaperCopy
**MaryvilleImagingReports _____Autofax(ifnotselected,reportwillbemanuallyfaxedwithinadayofsignature.Nopapercopy.)
OutpatientLabResults _____AutofaxOR ______PaperCopy
PathologyReports _____AutofaxOR ______PaperCopy
**MedicalRecordReports: _____AutofaxOR ______PaperCopy(IncludesdictatedreportssuchasH&P’s,consults,DischargeSummaries,etc.EKGsareanexceptionandarenotincludedinautofax.)
**AndersonMedicalGroupOfficeNotes _____Autofax OR ______PaperCopy
DEDICATEDFAXNumber: __________________________ _Inordertousetheservice,yourofficemusthaveaDEDICATED24HOURFAXLINE.
PhoneNumber: ________________________________________________________________(forquestionsrelatedtotheselectionsonthisform)
Fromtheoffice(s)of: _________________________________________ (PleasePrint)
PhysicianSignature: __________________________________________Date:____________
PrintedPhysicianName: _____________________________________
**Please note that dictated reports and x‐ray reports are not faxed until after they are electronicallysigned. Thepaperreportwillbeplaced inyourmailboxonly if the faxtransmission isnotsuccessful.Therearesix(6)attemptsatfaxingbeforeitisconsideredfailed.
Forquestionsregardingthisservice,pleasecontactHealthInformationManagementat618‐391‐6111or618‐391‐6105.
CONTINUING MEDICAL EDUCATION (CME’s)
List the continuing education sessions and hours which you have completed in the last two years. Attach either a copy of certificates of attendance for each program attended or list as follows:
Name of Program/Topic
Sponsored by
Dates of Attendance Hours
Total Hours
If requested, I agree to submit proof of attendance and program content. Provider Signature Date
618‐391‐6140 618‐288‐2164 FAX
Page 1 of 2
PROVIDER PEER REFERENCE
Applicant: Specialty: The above provider has applied for medical staff appointment to the staff of Anderson Hospital. The applicant has given your name as a reference, and we are asking you to render an opinion in the following categories. This is an important part of the evaluation of this provider’s application for surgical privileges. Your response will be treated as confidential.
Criteria Excellent Above Average Average Below Average
Clinical Knowledge
Clinical Judgement
Technical Proficiency
Professional Relations with Patients
Ethical Conduct
Record Keeping
1. How long have you known the above named applicant: year(s). From: to
(month/year) (month/year)
2. In what setting(s) and with what frequency did you observe the applicant? (i.e. office, hospital residency program, etc./daily, weekly, month, etc.)
3. Would you be pleased to have this applicant as an associate with you in practice? Yes _____ No
618‐391‐6140 618‐288‐2164 FAX
Page 2 of 2
4. To your knowledge, does the provider have any condition which could compromise his ability to perform any of the mental and physical functions related to the requested clinical privileges? Yes _____ No If yes, please explain:
5. To your knowledge, has the provider ever been denied membership or clinical privileges for any hospital system or medical staff? Yes _____ No If yes, please explain:
6. Any additional information which may be relevant to the evaluation of the provider:
My recommendation concerning this provider’s application for appointment/affiliation is:
Recommend Recommend with reservation* Not recommended* *Please explain any reservations or concerns regarding the applicant’s request for appointment/affiliation:
Signature/Title: Date: Printed Name:
618‐391‐6140 618‐288‐2164 FAX
Page 1 of 2
PROVIDER PEER REFERENCE
Applicant: Specialty: The above provider has applied for medical staff appointment to the staff of Anderson Hospital. The applicant has given your name as a reference, and we are asking you to render an opinion in the following categories. This is an important part of the evaluation of this provider’s application for surgical privileges. Your response will be treated as confidential.
Criteria Excellent Above Average Average Below Average
Clinical Knowledge
Clinical Judgement
Technical Proficiency
Professional Relations with Patients
Ethical Conduct
Record Keeping
1. How long have you known the above named applicant: year(s). From: to
(month/year) (month/year)
2. In what setting(s) and with what frequency did you observe the applicant? (i.e. office, hospital residency program, etc./daily, weekly, month, etc.)
3. Would you be pleased to have this applicant as an associate with you in practice? Yes _____ No
618‐391‐6140 618‐288‐2164 FAX
Page 2 of 2
4. To your knowledge, does the provider have any condition which could compromise his ability to perform any of the mental and physical functions related to the requested clinical privileges? Yes _____ No If yes, please explain:
5. To your knowledge, has the provider ever been denied membership or clinical privileges for any hospital system or medical staff? Yes _____ No If yes, please explain:
6. Any additional information which may be relevant to the evaluation of the provider:
My recommendation concerning this provider’s application for appointment/affiliation is:
Recommend Recommend with reservation* Not recommended* *Please explain any reservations or concerns regarding the applicant’s request for appointment/affiliation:
Signature/Title: Date: Printed Name:
618‐391‐6140 618‐288‐2164 FAX
Page 1 of 2
PROVIDER PEER REFERENCE
Applicant: Specialty: The above provider has applied for medical staff appointment to the staff of Anderson Hospital. The applicant has given your name as a reference, and we are asking you to render an opinion in the following categories. This is an important part of the evaluation of this provider’s application for surgical privileges. Your response will be treated as confidential.
Criteria Excellent Above Average Average Below Average
Clinical Knowledge
Clinical Judgement
Technical Proficiency
Professional Relations with Patients
Ethical Conduct
Record Keeping
1. How long have you known the above named applicant: year(s). From: to
(month/year) (month/year)
2. In what setting(s) and with what frequency did you observe the applicant? (i.e. office, hospital residency program, etc./daily, weekly, month, etc.)
3. Would you be pleased to have this applicant as an associate with you in practice? Yes _____ No
618‐391‐6140 618‐288‐2164 FAX
Page 2 of 2
4. To your knowledge, does the provider have any condition which could compromise his ability to perform any of the mental and physical functions related to the requested clinical privileges? Yes _____ No If yes, please explain:
5. To your knowledge, has the provider ever been denied membership or clinical privileges for any hospital system or medical staff? Yes _____ No If yes, please explain:
6. Any additional information which may be relevant to the evaluation of the provider:
My recommendation concerning this provider’s application for appointment/affiliation is:
Recommend Recommend with reservation* Not recommended* *Please explain any reservations or concerns regarding the applicant’s request for appointment/affiliation:
Signature/Title: Date: Printed Name: