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Transcript of THANK YOU FOR APPLYING TO THE MEDICAL STAFF c.ymcdn.com/sites/ · PDF file5 Specify...

  • THANK YOU FOR APPLYING TO THE MEDICAL STAFF OF OPELOUSAS GENERAL HEALTH SYSTEM. ATTACHED YOU WILL FIND AN APPLICATION, CLINICAL PRIVILEGE FORM, AS WELL AS OTHER FORMS NECESSARY FOR COMPLETING THE CREDENTIALING PROCESS. PLEASE COMPLETE THE ATTACHED FORMS AND NECESSARY DOCUMENTS, AS INDICATED, AND RETURN TO ME AS SOON AS POSSIBLE. 1. Letter indicating your request and reason for seeking privileges; (please address to William Bud

    Barrow, President and CEO. State your specialty and staff category requesting (Active, Courtesy or Consulting).

    2. Print or type and sign the attached application and the clinical privilege delineation forms. BLANKS MUST BE COMPLETED. STATING SEE CV WILL NOT BE ACCEPTED. If additional space is needed, attach additional sheet and make reference to the question being answered.

    3. Attach a copy of the following items:

    a. Curriculum vitae (make sure there is an accurate account of all time from the completion of medical school).

    b. Photocopy of all State Medical Licenses, ACLS, ATLS, BLS, NALS and PALS. c. Photocopy of Current State and Federal Narcotic Licenses. d. Photocopy of Current Professional Liability Insurance (Certificate of Insurance). e. Current Picture ID Photo f. Submit the names, addresses, and phone numbers of 3 references (one of which must be of the

    same specialty). Do not use program directors for references, as they will automatically be requested to complete a reference questionnaire.

    g. Submit the name, address and phone/fax number of the institution where Internship, Residency, and Fellowships were done. (Be sure to indicate your program directors name)

    h. List present as well as recent clinical affiliations including addresses and phone/fax numbers.

    i. Health Status Statement j. Submit copies of all CMEs received within your specialty k. Copy of Annual TB Skin test or x-ray l. Proof of Citizenship, (if foreign medical school graduate) m. Copy of EFCMG Certificate (if foreign medical school graduate) n. Submit your UPIN, Medicare and Medicaid Numbers (for billing purposes) o. Use the attached form to indicate who you made arrangements with to cover your practice when you are unavailable. (Must be a member of our Medical Staff) p. Notify the Medical Staff office, in writing, of Vacation days as well as days you will not be available for your practice.

    If you have any questions, please feel free to contact me at (337) 948-5168 or you may fax me at (337) 594-3895. Sincerely,

    Nicole Savoy Medical Staff Coordinator

  • February 20, 2008

    Dear Sir or Madam: Our firm provides credentialing and recredentialing verification services on behalf of _________________________________________________. All practitioners are required to complete the credentialing process prior to acceptance to the panel or medical staff. All verifications are kept strictly confidential, and we do not participate in any decision making processes. Enclosed are the following items for your review, completion and return:

    An initial credentials application A clinical practice privileges form, if applicable An authorization/release form A checklist of items to include with your application

    This is the only notification we will be sending to you, therefore, please complete the required documents and return them directly to us within fifteen (15) days of the date of this letter. Please contact one of our credentials analysts at (505) 343-0070, if you have any questions or require any additional information. Sincerely, Credentials Verification Services Enclosures Rev. October, 2003

  • Name(s) of Health Care Organization(s) to Which Application is Being Made

    Date of Application:

    Name: Last First Middle Other Names Used Circle all that apply and for which you are currently licensed: MD DO DDS DC DPM OD PA CNM CNP CRNA RN PT OT ST DOrienMed Acup Clin Psych Psych Assoc LMHC LPAT LADAC LISW LMSW LPC LPCC LMFT CNS/Psych CNS/Medical Spch Path Other: Specialty:

    Gender: F M Citizenship: Place of Birth:

    Social Security Number: Date of Birth:

    State Tax ID#: Pending Federal Tax ID#: Pending Medicare #: Pending Medicaid #: Pending

    Unique Physician Identification Number (UPIN): Pending Office Manager or Contact Person and telephone number:

    Practice/Group Name: Effective Date:

    Street Address:

    City, State and Zip Code:

    Telephone Number: Facsimile Number:

    E-Mail Address: Answering Service Number:

    Can we contact you by e-mail for credentialing correspondence? Yes No

    Foreign Languages (spoken fluently by practitioner):

    Foreign Languages (spoken fluently at practice):

    Current Mailing Address (if different from above): Same As Above

    Street Address:

    City, State and Zip Code:

    Telephone Number: Facsimile Number:

    Are you requesting to be credentialed as a primary care provider (PCP)? Yes No

    Do you deliver babies? Yes No

  • 4

    Billing Address (if different from mailing address): Same As Mailing Address

    Contact Person:

    Street Address:

    City, State and Zip Code:

    Telephone Number: Facsimile Number:

    Other Practice Locations: (Attach a separate page for additional practice locations.)

    Practice Name: Street Address:

    City, State and Zip Code:

    Telephone Number: Facsimile Number:

    Home Address: Street Address:

    City, State and Zip Code:

    Telephone Number: Pager Number:

    Spouses Name (Optional):

    Practice Associates: Call Coverage (if different):

    / / / / What are the office hours for your Practice or Group Practice? (Provide days/hours):

    What provisions have been made for after hours?

    PROFESSIONAL REFERENCES

    Please list five professional peers with the same type of license or a higher level of licensure who are familiar with your professional performance in the past five (5) years (not including current or impending partners or associates in practice).

    Name and Title: Street Address:

    City, State, Country and Zip Code:

    Telephone Number: Facsimile:

    Name and Title: Street Address:

    City, State, Country and Zip Code:

    Telephone Number: Facsimile:

  • 5

    Specify Internship, Residency, or Fellowship

    Specify Internship, Residency, or Fellowship

    Name and Title: Street Address:

    City, State, Country and Zip Code:

    Telephone Number: Facsimile:

    Name and Title: Street Address:

    City, State, Country and Zip Code:

    Telephone Number: Facsimile:

    Name and Title: Street Address:

    City, State, Country and Zip Code:

    Telephone Number: Facsimile:

    EDUCATION Undergraduate Education:

    College or University: Street Address:

    City, State, Country and Zip Code:

    Dates Attended: From To Degree Earned:

    Graduate Education: (List all medical, osteopathic, dental or podiatric schools attended.)

    College or University: Street Address:

    City, State, Country and Zip Code:

    Dates Attended: From To Degree Earned:

    POST GRADUATE TRAINING N/A List all hospitals where you received training and attach a copy of your certificate. Disclose every residency program initiated, whether completed or not, and all completed programs. Attach a separate page, if necessary. Specialty:

    Institution: Dates Attended: From

    Street Address: To

    City, State, Country and Zip Code:

    Specialty:

    Institution: Dates Attended: From

    Street Address: To

    City, State, Country and Zip Code:

  • 6

    Specify Internship, Residency, or Fellowship

    Specialty:

    Institution: Dates Attended: From

    Street Address: To

    City, State, Country and Zip Code:

    Teaching Appointments N/A

    Institution:

    Street Address:

    City, State, Country and Zip Code:

    Dates Attended: From To Department/Position:

    WORK HISTORY

    Please list all previous experience for the past fifteen (15) years, including months and years, listing the most recent first. Attach a separate page, if necessary. Please provide a written explanation for any gaps in work history of six (6) months or more. Organization: Dates: From To Mo/Yr Mo/Yr Street Address:

    City, State, Country and Zip Code:

    Telephone Number: Contact Person:

    Organization: Dates: From To Mo/Yr Mo/Yr Street Address:

    City, State, Country and Zip Code:

    Telephone Number: Contact Person: Organization: Dates: From To Mo/Yr Mo/Yr Street Address:

    City, State, Country and Zip Code:

    Telephone Number: Contact Person:

    Organization: Dates: From To Mo/Yr Mo/Yr Street Address:

    City, State, Country and Zip Code:

    Telephone Number: Contact Person:

    Organization: Dates: From To Mo/Yr Mo/Yr Street Address:

    City, State, Country and Zip Code:

    Telephone Number: Contact Person:

  • 7

    HOSPITAL AND HEALTHCARE AFFILIATIONS Are you a: Doctor of Medicine (MD)? Yes No

    Doctor of Osteopathic Medicine (DO)? Yes No Certified Nurse Practitioner (CNP) a