CREDENTIALS OF EMERGENCY DEPARTMENT PHYSICIANS



-601980-212090CREDENTIALS OF EMERGENCY DEPARTMENT PHYSICIANS (APPENDIX 5)00CREDENTIALS OF EMERGENCY DEPARTMENT PHYSICIANS (APPENDIX 5)ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDRENPCCC/EDAP APPLICATIONCREDENTIALS OF EMERGENCY DEPARTMENT PHYSICIANSList each physician by name.Indicate full time or part time and date of ED hire.List all credentials that qualify physician for EDAP or SEDP status. For all physicians who do not meet any of the Board Certifications listed below and who do not meet Alternate Criteria requirements, submit their curriculum vitae, other Board Certifications and copies of their Residency Completion. Identify any physicians that meet Alternate Criteria requirements and submit required documentation including confirmation of hours worked (Adm. Code 515.4000 a,1,D)Identify completion of APLS or PALS and expiration date. Submit a copy of a current AHA PALS or ACEP-AAP APLS card for those physicians who meet Alternate Criteria.Identify the number of pediatric CME hours completed within the past 2 years. Submit a copy of pediatric CME hours for those physicians who meet Alternate Criteria.Physician NameF=Full TimeP=Part TimeDate of ED HireBoard Certification (Or Board Eligible in 1st cycle)ABEM/AOBEM/ABP/AOBP/ABFM/AOBFMor Alternate Criteria Exp.orMOCExp.DateCourseCompletionExp.Date# of HRS of Pediatric Emergency related CME(16 HRS/past 2 years required)APLSPALS1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? 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FORMTEXT ?????SignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)PCCC AND EDAP APPLICATION RENEWAL PACKET (APPENDIX 5)1-179070-246380CREDENTIALS OF FAST TRACK/URGENT CARE PHYSICIANS (APPENDIX 6)00CREDENTIALS OF FAST TRACK/URGENT CARE PHYSICIANS (APPENDIX 6)ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDRENPCCC/EDAP APPLICATIONCREDENTIALS OF FAST TRACK/URGENT CARE PHYSICIANSList each physician by name.Indicate full time or part time status and date of ED plete all credentials and list any board certifications.Identify completion of APLS or PALS and expiration date.Identify the number of pediatric CME hours that have been completed within the past 2 years.Physician NameF=Full TimeP=Part TimeDate of ED HireBoard Certification Exp.orMOCExp.DateCourseCompletionExp.Date# of HRS of Pediatric Emergency related CME(16 HRS/past 2 years required)APLSPALS1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????6 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????7 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????8 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????9 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????10 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)PCCC AND EDAP APPLICATION RENEWAL PACKET (APPENDIX 6) 238100-224790CREDENTIALS OF EMERGENCY DEPARTMENT MID LEVEL PROVIDERS (APPENDIX 7)00CREDENTIALS OF EMERGENCY DEPARTMENT MID LEVEL PROVIDERS (APPENDIX 7)ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDRENPCCC/EDAP APPLICATIONCREDENTIALS OF EMERGENCY DEPARTMENT NURSE PRACTITIONER, CLINICAL NURSE SPECIALIST AND PHYSICIAN ASSISTANTList each nurse practitioner and physician assistant by name.Indicate location of work site: Emergency Department or Fast Track only.Verify current license and check all credentials. (PAs: check appropriate box; NP: specify ACPNP, PCPNP, PCCNP, ENP, FPNP or Alternate Criteria; CNS: specify pediatric certification)Nurse Practitioners shall have completed a Pediatric NP, Emergency NP or Family Practice NP program. Identify any nurse practitioner that meets Alternate Criteria requirements and submit a letter verifying his or her hours worked (EMS Administrative Code 515.4000 b,1,A, ii)Identify completion of APLS, PALS or ENPC. Submit a copy of a current AHA PALS or ACEP-AAP APLS or ENPC card for the nurse practitioner who meets Alternate CriteriaIdentify the number of pediatric CME/CEU hours that have been completed within the past 2 years. Minimally need to meet 16 hrs/2 yrsClinician NameEDEmergencyDepartmentFTFast TrackonlyDateofED HireLicense VerificationExp.DateFacilityCredentialingFor PediatricCareY/NCourse CompletionExp.Date# of HRS of Pediatric Emergency CME/CEU(16 HRS/past 2 years required)PAACPNP, PCPNP, PCCNP, ENP, FPNP, or Alternate CriteriaCNS Pediatric Certification (AACN/ANCC)APLSPALSENPC1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? 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FORMTEXT ?????SignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)PCCC AND EDAP APPLICATION RENEWAL PACKET (APPENDIX 7) 357150-184150CREDENTIALS OF EMERGENCY DEPARTMENT NURSING STAFF (APPENDIX 8)00CREDENTIALS OF EMERGENCY DEPARTMENT NURSING STAFF (APPENDIX 8)ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDRENPCCC/EDAP APPLICATIONCREDENTIALS OF EMERGENCY DEPARTMENT NURSING STAFFList each staff nurse by name.Indicate full time or part time status and date of ED hire.Identify completion of APLS, PALS or ENPC, and expiration date.Identify the number of pediatric CEU’s that have been completed within the past 2 years.Staff NurseF=Full TimeP=Part TimeDate of ED HireCourse CompletionExpirationDate# HRS of Pediatric Emergency/Critical Care CEUs (8 HRS/past 2 years required)EDAP – All RN’sSEDP – One RN/ShiftAPLSPALSENPC1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????6 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????7 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????8 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????9 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? 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FORMTEXT ?????SignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)PCCC AND EDAP APPLICATION RENEWAL PACKET (APPENDIX 8) 488900-249555CREDENTIALS OF PEDIATRIC INTENSIVE CARE UNIT PHYSICIANS (APPENDIX 9)00CREDENTIALS OF PEDIATRIC INTENSIVE CARE UNIT PHYSICIANS (APPENDIX 9)ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDRENPCCC/EDAP APPLICATIONCREDENTIALS OF PEDIATRIC INTENSIVE CARE UNIT PHYSICIANSList each physician by name.Indicate full time or part time status.Identify Board Certification for each physician.Identify completion of APLS or PALS course, and expiration date.Physician NameF=Full TimeP=Part TimeDate of HireCertification as Pediatric Intensivist with Dual Certifications: ABP and Pediatric Critical Care Medicine or AOBP and Pediatric Intensive Care or Board Eligible Pediatric IntensivistExp.DateCourseCompletionExp.DateAPLSPALS1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????6 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????7 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????8 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????9 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????10 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)PCCC AND EDAP APPLICATION RENEWAL PACKET (APPENDIX 9) 5-53163-342368CREDENTIALS OF PICU MID LEVEL PROVIDERS (APPENDIX 10)00CREDENTIALS OF PICU MID LEVEL PROVIDERS (APPENDIX 10)ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDREN PCCC/EDAP APPLICATIONCREDENTIALS OF PICU NURSE PRACTITIONERS, CLINICAL NURSE SPECIALISTS AND PHYSICIAN ASSISTANTSList each nurse practitioner and physician assistant by name.Verify current license and check all credentials. (PA: check appropriate box; NP: specify PNP or PCCNP, and identify certification as ACPNP; CNS: specify pediatric certification)Identify Y/N for facility credentialing for pediatric care.Identify completion of APLS, PALS or ENPC, and identify expiration date.Identify the number of pediatric CME/CEU hours that have been completed within the past 2 years. Minimally need to meet 50 hrs/2 yrsClinician NameDateofPICU HireLicense VerificationExp.DateFacilityCredentialingFor PediatricCareY/NCourse CompletionExp.Date# of HRS of Pediatric Emergency CME/CEU(50 HRS/past 2 years required)PAPNP or PCCNP; Certificationas ACPNPCNS Pediatric Certification (AACN/ANCC)APLSPALSENPC1 FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? 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FORMTEXT ?????SignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)PCCC AND EDAP APPLICATION RENEWAL PACKET (APPENDIX 10) 6ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDREN190500-563880CREDENTIALS OF PICU NURSING STAFF (APPENDIX 11)00CREDENTIALS OF PICU NURSING STAFF (APPENDIX 11) PCCC/EDAP APPLICATIONCREDENTIALS OF PICU NURSING STAFFList each staff nurse by name.Indicate full time or part time status and date of hire.Identify completion of APLS, PALS or ENPC, and expiration date.Identify the number of pediatric CEU’s that have been completed within the past two years.Staff NurseF=Full TimeP=Part TimeDate of HireCourse CompletionExpirationDate16 HRS. of Pediatric CEU’s (In Last Two Years)APLSPALSENPC1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????6 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????7 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????8 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????9 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????10 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)PCCC AND EDAP APPLICATION RENEWAL PACKET (APPENDIX 11) 70-236043CREDENTIALS OF PEDIATRIC UNIT HOSPITALISTS (APPENDIX 12)00CREDENTIALS OF PEDIATRIC UNIT HOSPITALISTS (APPENDIX 12)ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDRENPCCC/EDAP APPLICATIONCREDENTIALS OF PEDIATRIC UNIT HOSPITALISTSList each physician by name.Indicate full time or part time status.Identify Board Certification for each physician.Identify completion of APLS or PALS course, and expiration date.Physician NameF=Full TimeP=Part TimeDate of HireBoard Certification(Identify type of board certification)Exp.DateCourseCompletionExp.DateAPLSPALS1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????6 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????7 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????8 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????9 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????10 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)PCCC AND EDAP APPLICATION RENEWAL PACKET (APPENDIX 12) 8ILLINOIS EMERGENCY MEDICAL SERVICES FOR CHILDREN152400-490855CREDENTIALS OF PEDIATRIC UNIT NURSING STAFF (APPENDIX 13)00CREDENTIALS OF PEDIATRIC UNIT NURSING STAFF (APPENDIX 13)PCCC/EDAP APPLICATIONCREDENTIALS OF PEDIATRIC UNIT NURSING STAFFList each staff nurse by name.Indicate full time or part time status and date of hire.Identify completion of APLS, PALS or ENPC, and expiration date.Identify the number of pediatric CEU’s that have been completed within the past two years.Staff NurseF=Full TimeP=Part TimeDate of HireCourse CompletionExpirationDate16 HRS. of Pediatric CEU’s (In Last Two Years)APLSPALSENPC1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????6 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????7 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????8 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????9 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????10 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)PCCC AND EDAP APPLICATION RENEWAL PACKET (APPENDIX 13) 9 ................
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