Anderson Hospital · Anderson Hospital Supplemental Information Form (3 pages) NOTE: the last page...

Anderson Hospital 6800 State Route 162

Maryville, Illinois 62062 [email protected]

Re: Application Documentation Dear ____________________________: 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 By-Laws, Rules and Regulations. This form may also be obtained from the website, downloaded as a Word document, completed and saved on your computer. PLEASE MAKE SURE TO COMPLETE THE CORRECT FORM – CREDENTIALING VS. RECREDENTIALING. If a section or question does not apply to you such as additional names known by 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 (3 pages) 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 (1 page)(original signature required) Anderson Hospital – Medical Staff member Consent and Release (1 page)(original signature required) Anderson Hospital – Health Statement (1 page) NOTE: Please sign the form at the top and forward to

your private physician or schedule your physical with your private physician and have them complete the form and return to our office via mail or fax. (618)288-2164

Exhibit B – MHA Management Services Corporation – Background Check Request Form – this form MUST be completed in order for the Medical Staff Office to run a State of Illinois 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. (completed original copy with original signature must 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. (original signature required)

Delineation of Privilege Forms – 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.

Memorandum of Medical Reports Faxing – if you wish to receive faxed reports Notice to Physicians regarding Champus, Medicare, Medicaid – REQUIRED and must be Original Signature Card Provider Contact Information (in order by preference) 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 one hundred and eighty (180) 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 Tracine Kempfer, Medical Staff Manager at 618-391-6140. Thank you for your interest in Anderson Hospital.

Sincerely,

UÜxàà ZÜxu|Çz? `W Brett Grebing, MD – President Elect Chairman of the Credentials Committee

Anderson Hospital – Maryville, IL 6800 State Route 162

Medical Staff Office: 618-391-6140 [email protected]

Application Checklist

Instructions for Completing State Mandated Form - Please read carefully (PAGE #2 MUST BE ORIGINAL SIGNATURE RETURNED)

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 be provided. 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


F. Section F. Hospital Membership – Previous Addresses must be complete and current. If a letter is returned – the applicant is responsible to get the


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


H. Section H. Work History Addresses must be complete and current. If a letter is returned – the applicant is responsible to get the


I. Section I. Professional References Addresses must be complete and current. If a letter is returned – the applicant is responsible to get the


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 numbers B. Section M. Additional Site Information - complete only through the phone and fax numbers

3. Attach Forms A - F as required.

A. Form B - If you complete this form, please provide the following:

Name of Court Name & Address of Attorney defending you

Anderson Hospital – Maryville, IL 6800 State Route 162

Medical Staff Office: 618-391-6140 [email protected]

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 7. Clear Photo of you to be used for identification purposes 8. Application fee of $400 for physicians- Make check payable to Anderson Hospital

Anderson Hospital

6800 State Route 162 Maryville, Illinois 62062

Attn: Medical Staff Office 618-391-6141

[email protected]

INVOICE

Application Fee – _______________________________ $ 400.00 (Physicians) (Print name)

Please submit a check made payable to Anderson Hospital – This check MUST accompany the Application to deem the application complete!

Anderson Hospital 6800 State Route 162, Maryville, Illinois

618-391-6141 [email protected]

Supplemental Information

Name: ___________________________________ 1. Home Address ______________________________________________________________________________________

____________________________________________________________________________________ 2. Home Phone _______________________________________________________________________________________

3. Marital Status (optional) _______________________________________________________________________________

4. Name of Significant Other (optional) _____________________________________________________________________ 5. Suffix (Jr., Sr., III, etc.) _______________________________________________ 6. Name(s) of physician(s) on staff at Anderson Hospital, with the same specialty as yours, who will provide coverage. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

1. Has your present professional liability insurance carrier excluded any specific area of practice from your insurance coverage?

Yes _______ No _______ If yes, explain ________________________________________________________________________________________ ____________________________________________________________________________________________________ _____________________________________________________________________________________________________

2. Have any professional liability suits ever been filed against you?

Yes _______ No _______ If yes, explain _________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 3. Are there currently any pending or final judgments or settlements against you in regards to professional medical liability

action? Yes _______ No _______

If yes, explain __________________________________________________________________________________________ ______________________________________________________________________________________________________ _______________________________________________________________________________________________________

Page 1 of 3

mailto:[email protected]

Anderson Hospital Supplemental Information

4. 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 _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

5. 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 _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

6. 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 _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

13. If you resigned from a facility, were there any disciplinary actions or investigations in process at that time?

Yes _______ No _______ If yes, explain

_____________________________________________________________________________________________

_____________________________________________________________________________________________

14. Have you ever had any voluntary or involuntary suspension or non-renewal of Medical Staff membership or clinical privileges?

Yes _______ No _______ If yes, explain _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

Page 2 of 3

Anderson Hospital Supplemental Information 15. Have you ever been asked to surrender your license? Yes _______ No _______

If yes, explain ________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

16. 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 ________________________________________________________________________________________ ____________________________________________________________________________________________________ _____________________________________________________________________________________________________

17. 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 _________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

18. 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 _________________________________________________________________________________________ _____________________________________________________________________________________________________ ______________________________________________________________________________________________________

19. **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

Page 3 of 3

Anderson Hospital Medical Staff Status Description

Page 1 of 2

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 ten (10)

patients each reappointment cycle and/or attend not fewer than ten (10) 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. Members will refer not fewer than twenty-one (21) patients to hospital services per year. Members of the Active Staff with Membership Only who fail to attend required meetings, will be assigned to the

Membership Only staff. 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 twelve (12)

patients each calendar year. 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 eleven (11) patients in one year. Physicians admitting or

performing procedures on more than eleven (11) 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. No admitting privileges.

Anderson Hospital Medical Staff Status Description

Page 2 of 2

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 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 privileges.

Anderson Hospital 6800 State Route 162, Maryville, IL 62062

Medical Staff Office 618-391-6141

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


Medical Staff Office 618-391-6141

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 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

618‐391‐6141

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

mersingerb

Rectangle

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: __________________

Anderson Hospital Illinois Route 162

Maryville, Illinois 62062 Attn: Medical Staff Office

618-391-6140 or 618-391-6141 [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. 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.

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:

________________________________________________________

This signature card is kept on the nursing unit for reference purposes.

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 Policy of Anderson. 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/Chair 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 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. ___________________________________________ ________________________ Signature Date ___________________________________________ Printed Name ___________________________________________ Medical Specialty Please list any actual or potential conflicts of interest that may be present as defined in this agreement. If there are no actual or potential conflicts of interest, enter: “None”. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

INSURANCE TO ALL MEDICAL STAFF MEMBERS: The Board Trustees on April 25, 1989, approved the Medical Staff By-Laws change concerning malpractice insurance and passed a Board resolution allowing for the following limits of malpractice insurance: A. Physicians granted privileges in the areas of Obstetrics and Gynecology, Anesthesia,

Orthopedic Surgery, Radiology, Pathology, Neurosurgery, General Family Practice including OB/GYN, and those retained to provide coverage in the Emergency Department will maintain a minimum of $1,000,000.00 per event or $3,000,000.00 on the aggregate.

B. Those physicians granted privileges in Internal Medicine, Cardiology, General Family

Practice excluding OB/GYN, General and Vascular Surgery, Ophthalmology, Gastroenterology, Otolaryngology, Dermatology, Urology, Pulmonary, Plastic Surgery, Rheumatology, Nephrology, Neurology, Chemotherapy, Psychiatry and Oral Surgery shall retain a minimum of $1,000,000.00 per occurrence and $1,000,000.00 in the aggregate.

C. Podiatrists (excluding orthopedic privileges) shall maintain a minimum of $200,000.00

per event or $600,000.00 in the aggregate. D. General Dentist (excluding oral surgeons) shall maintain $500,000.00 per occurrence and

$500,000.00 in the aggregate. E. All others who have privileges to admit patients to, or to treat patients in, Anderson

Hospital shall maintain $1,000,000.00 per occurrence and $1,000,000.00 in the aggregate. ***It is required that we retain proof of insurance and Anderson Hospital is to be named as the certificate holder.

***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

NOTICE TO PROVIDERS

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 “NOTICE TO PROVIDERS” concerning Medicare, Medicaid and Champus payment to hospitals and the penalties as stated.

___________________________________ ______________________ Provider’s Signature Date ___________________________________ Printed Name

AUTOFAX ENROLLMENT FORM

Request to Enroll Request to Revise Request to Remove The autofax service can be utilized to provide your office with immediate faxed receipt of various medical reports. Please indicate whether you wish to receive reports from one or more of the following report categories: **Radiology Reports _____Autofax OR ______Paper Copy in Mailbox

**Maryville Imaging Reports _____Autofax (if not selected, report will be manually faxed . within a day of signature. No paper copy.)

**Outpatient Lab Results _____Autofax OR ______Paper Copy in Mailbox ** Inpatient Discharge Lab Summary _____Autofax PAPER COPY NOT AVAILABLE (This is an optional report)

**Pathology Reports _____Autofax OR ______Paper Copy in Mailbox

**Medical Record Reports: _____Auto fax OR ______Paper Copy in Mailbox

(Includes dictated reports such as H & P’s, consults, Discharge Summaries, etc. EKGs are an exception and are not included in autofax.)

DEDICATED FAX Number: (_______) ___________________________

In order to use the service, your office must have a DEDICATED 24 HOUR FAX LINE. From the office (s) of: ___________________________________ Printed Physician Name: ______________________________________ Physician Signature: __________________________________________ Date: ____________ Please note that dictated reports and X-ray reports are not faxed until after they are electronically signed. NOTE: The paper report will be placed in your mail box only if the fax transmission is not successful. There are 6 attempts at faxing made before it is considered failed.

For questions regarding the service, please contact the Medical Staff Office at 618-391-6140. Return this completed form to the Medical Staff Office or email to: [email protected]

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


Medical Staff Office Telephone (618) 391-6140

Fax: (618) 288-2164 [email protected]

Page 1 of 4

PROFESSIONAL REFERENCE QUESTIONNAIRE Date: To: The applicant listed below has applied for privileges at Anderson Hospital: Applicant: ____________________ Specialty: _ _ ________________ Your name has been given to us as a professional/personal reference. Before proper action can be taken on the application, we require additional information from you. A copy of privileges requested is enclosed as well as a consent to release this information. Please answer the following questions, sign, and return at your earliest convenience to the above address or fax. How long have you known the above named applicant: _____ years. From _________ to _________ (month/year) (month/year) During what time period did you have the opportunity to directly observe the applicants practice of medicine? _____ Past 6 months _____ Last 1 -2 years Other: _____ Explain:__________________________________________________________________________________________________________________________________________________ In what setting(s) and with what frequency did you observe the applicant (i.e., office, hospital, residency program, etc. or daily, weekly, monthly, infrequently)? ___________, patient care in hospital setting: ________________________________________________________________________________________________________________________________________________________ Were you previously, are you now, or are you about to become related to the applicant as family or through a professional partnership or financial association? _____Yes _____ No If yes, please explain: ________________________________________________________________________________________________________________________________________________________ Have you ever observed or been informed of any physical, mental, and/or emotional health problems including any use of alcohol or drugs, which the applicant has or had that have or could potentially affect his/her ability to exercise all or any of the privileges requested or to perform the duties of medical staff appointment? _____Yes _____ No _____ No Information If yes, please explain: ________________________________________________________________________________________________________________________________________________________




Page 2 of 4

To the best of your knowledge has the applicant’s license, clinical privileges, hospital appointment, affiliation with any healthcare organization, or other professional status ever been denied, challenged, investigated, terminated, reduced, not renewed, limited, withdrawn, suspended, revoked, modified, placed on probation, relinquished, or voluntarily surrendered, or do you have knowledge of any such actions that are pending? _____ Yes _____ No _____ No Information If yes, please explain: ________________________________________________________________________________________________________________________________________________________ Do you know of any malpractice action instituted or in process against the applicant? _____ Yes _____ No _____ No Information If yes, please explain: ________________________________________________________________________________________________________________________________________________________

Please rate the following: Poor Fair Good Superior No Knowledge

Medical/Clinical Knowledge ( ) ( ) ( ) ( ) ( )

Technical/Clinical Skills ( ) ( ) ( ) ( ) ( ) Clinical Judgment ( ) ( ) ( ) ( ) ( )

Interpersonal Skills ( ) ( ) ( ) ( ) ( ) Communication Skills ( ) ( ) ( ) ( ) ( ) Professionalism ( ) ( ) ( ) ( ) ( ) Sense of Responsibility ( ) ( ) ( ) ( ) ( )

Patient Management ( ) ( ) ( ) ( ) ( ) Ethical Conduct ( ) ( ) ( ) ( ) ( )

Emotional Stability ( ) ( ) ( ) ( ) ( )

Cooperativeness, Ability to Work with Others ( ) ( ) ( ) ( ) ( ) Communication with Patients, Patients Family and Staff ( ) ( ) ( ) ( ) ( ) Record Keeping ( ) ( ) ( ) ( ) ( )

Physician/Patient Relationship ( ) ( ) ( ) ( ) ( )




Page 3 of 4

My recommendation concerning the specific clinical privileges/services requested is: _____ Recommend for all requested privileges/services _____ Not recommend certain privileges/services* _____ Limit certain privileges/services* _____ Not recommend for any privileges/services* * Please explain your recommendation:_____________________________________________ ________________________________________________________________________________________________________________________________________________________ To the best of your knowledge does the applicant meet the applicable criteria for each privilege requested? ____ Yes ____No ____No Information If not, please explain: ____________________________________________________________________________ ____________________________________________________________________________ My recommendation concerning this practitioner’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: ____________________________________________________________________________ ____________________________________________________________________________ Please use this section for any additional comments, information, or recommendations that may be relevant to our decision to grant appointment/affiliation or specific clinical privileges/services to the applicant. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________




Page 4 of 4

_______________________________________________ _________________ Print Name/Specialty Date

_______________________________________________ ________________________ Signature Phone No.

Please return this form to: [email protected] Or mail to: Anderson Hospital Medical Staff Office 6800 State Route 162 Maryville, IL 62062




Page 1 of 4





Page 2 of 4













Page 3 of 4





Page 4 of 4







Page 1 of 4





Page 2 of 4













Page 3 of 4





Page 4 of 4




Anderson Hospital · Anderson Hospital Supplemental Information Form (3 pages) NOTE: the last page...

Documents

Transcript of Anderson Hospital · Anderson Hospital Supplemental Information Form (3 pages) NOTE: the last page...