EXHIBIT C - University Health Care System



|UNIVERSITY HOSPITAL |

|Medical Staff |

|Policy & Procedure |

|Title: |Policy #: |Approval: |

|Verifications and Primary Sources |MS-16 |01/05 |

|Approved by: |Pages: |Revised/Reviewed Date: |

| |5 | |

| | |03/07 |

|____________________________ ____________ | | |

|Chief Medical Officer Date | | |

POLICY:

It is the policy of University Hospital to authenticate the credentials listed in applications submitted by practitioners desiring Medical Staff membership or affiliation. The validation process will be conducted in compliance with current JCAHO standards. Verifications may be via oral report, telephonic communications, visual inspection, electronic database interface or in writing.

PROCEDURE:

University Hospital will perform the following minimum verifications:

Note: The verification methods and requirements document lists verification elements that apply to all practitioners . There may be additional items to verify, depending on the privileges that an applicant has requested. These verifications should be incorporated into the process at the appropriate time.

180-day rule means that the item must have been received and verified within 180 days of making the final credentialing decision. This is typically applied to information that is subject to change

|Credentialing Item |Method of Verification |

| | |Initial Appointment|Reappointment |Update as |New Privilege(s) |

| | | | |Expires | |

|State license to practice |Primary Source via Web site |X |X |X |X |

| | | | | | |

|Verify current license, |180-day rule applies | | | | |

|expiration date, and | | | | | |

|sanctions/limitations. | | | | | |

|Licenses to practice in other |Primary source via |X |X |X |X |

|states (all current and past) |In writing/mail | | | | |

| |By phone/fax | | | | |

|Verify current license, |By Web site, if an approved Web site | | | | |

|expiration date, and | | | | | |

|sanctions/limitations. |180-day rule applies | | | | |

|DEA registration |Obtain copy from practitioner |X |X |X | |

| | | | | | |

|Verify DEA registration number,| | | | | |

|expiration date, schedules. | | | | | |

|Medical school (domestic |Primary Source via: |X | | | |

|graduates) |Confirm directly with medical | | | | |

| |school/professional school in writing or | | | | |

|Or other professional schooling|orally | | | | |

|relevant to privileges |AMA profile | | | | |

|requested (nonphysician | | | | | |

|applicants). | | | | | |

| | | | | | |

|Verify institution, completion | | | | | |

|date, and degree received. | | | | | |

|ECFMG (foreign graduates) |Contact information: |X | | | |

| | | | | | |

|Graduation from a foreign |Educational Commission for Foreign | | | | |

|medical school (does not cover |Medical Graduates | | | | |

|internships and fellowships). |3624 Market Street, 4th Floor | | | | |

| |Philadelphia, PA 19104-2685 | | | | |

|Verify ECFMG number and date | | | | | |

|issued. |Tel: 215/386-5900 | | | | |

| | | | | | |

| | | | | | |

|Internship/Other professional |Primary Source via: |X | | | |

|training |Confirm directly with internship program | | | | |

| |in writing or orally | | | | |

|Completed after medical school |AMA profile | | | | |

|graduation OR post receipt of | | | | | |

|ECFMG. | | | | | |

| | | | | | |

|Verify institution, begin/end | | | | | |

|dates, type of internship, and | | | | | |

|successful completion. | | | | | |

|Residency/Other professional |Primary Source via: |X | | |X |

|training |Confirm directly with residency program | | | |Verify any new |

| |in writing or orally | | | |education or |

|Completed after medical school |AMA profile | | | |professional training |

|graduation OR post receipt of | | | | |that may be required |

|ECFMG. | | | | |for the privilege(s) |

| | | | | |requested or that may |

|Verify institution, begin/end | | | | |provide information |

|dates, type of residency, and | | | | |about the applicant’s |

|successful completion. | | | | |competency to perform |

| | | | | |the requested new |

| | | | | |privilege(s). |

|Fellowship/Other professional |Primary Source via: |X | | |X |

|training |Confirm directly with fellowship program | | | |Verify any new |

| |in writing or orally | | | |education or |

|Completed after medical school |AMA profile | | | |professional training |

|graduation OR post receipt of | | | | |that may be required |

|ECFMG. | | | | |for the privilege(s) |

| | | | | |requested or that may |

|Verify institution, begin/end | | | | |provide information |

|dates, type of fellowship, and | | | | |about the applicant’s |

|successful completion. | | | | |competency to perform |

| | | | | |the requested new |

| | | | | |privilege(s). |

|Board certification or other |Primary Source via: |X |X | X |X |

|professional certification or |Confirm directly with certifying board | |If applicant received | |If any new |

|registration |(or the ABMS or AOA) in writing, orally, | |any new certifications | |certifications have |

| |or electronically (via an authorized Web | |during the previous | |been obtained since |

|All specialty board |site). Any other authorized ABMS source, | |appointment period | |the previous |

|certifications (may be |must be designated as an “Official ABMS | | | |appointment period |

|multiple) that are American |Display Agent” by the ABMS. | | | |that would qualify the|

|Board of Medical Specialties |CertiFax (has been designated as an | | | |applicant for the new |

|(ABMS) or American Osteopathic |Official ABMS Display Agent) | | | |privilege(s). |

|Association (AOA)-approved (for| | | | | |

|physicians). | | | | | |

| |180-day rule applies | | | | |

|Verify certifying board, | | | | | |

|specialty of certification, | | | | | |

|date certified/recertified, and| | | | | |

|expiration date, if applicable.| | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

|Military service |If military service was within past 10 | | | | |

| |years, contact hospitals where applicant | | | | |

|Get copy of DD-214 |provided services. | | | | |

| | | | | | |

| |If military service was longer than 10 | | | | |

| |years ago and it is deemed necessary to | | | | |

| |verify millitary history longer than 10 | | | | |

| |years ago contact: |X | | | |

| |Military Records Center | | | | |

| |9700 Page Boulevard | | | | |

| |St. Louis, MO 63132 | | | | |

| | | | | | |

| |(Note: Provide Social Security number, | | | | |

| |date of birth, date of service, release | | | | |

| |of information.) | | | | |

|Healthcare organization |Primary Source via: |X |X | |X |

|affiliations | |All affiliations | | |If needed to confirm |

| |Write directly to healthcare organization|for past 10 years | | |exercise of requested |

|Hospitals, ambulatory |or contact via telephone inquiry. | | | |new privilege(s) at |

|facilities, etc. | | | | |another facility. |

| |180-day rule applies | | | | |

|Work history |Primary Source via: |X |X | | |

| | | |Only applies if | | |

|Obtain from applicant on |Write directly to work places or contact | |applicant has been on | | |

|application. There should be no|via telephone inquiry. | |leave of absence since | | |

|unaccounted for gaps in time | | |previous credentialing | | |

|beginning with date of |180-day rule applies | |event. | | |

|graduation from | | | | | |

|medical/professional school or | | | | | |

|date of receipt of ECFMG. It is| | | | | |

|not required, however, that all| | | | | |

|time be verified. | | | | | |

| | | | | | |

|Follow up with applicant (and | | | | | |

|healthcare organizations, | | | | | |

|individuals, etc., as | | | | | |

|appropriate) and obtain | | | | | |

|explanation for any gaps in | | | | | |

|time of three month(s) or more.| | | | | |

|Professional liability |Primary Source via: |X | |X | |

|insurance | |Certificate copy |X |Certificate | |

| |Applicant provides on application form a |from current |If current copy is about|copy from | |

| |listing of current and past carriers. |carrier(s) provided|to expire, certificate |current | |

| |Obtain certificate of insurance directly |by applicant |copy from |carrier(s) | |

| |from applicant | |current carrier(s) |provided by | |

| | | |provided by applicant |applicant | |

| |180-day rule applies | | | | |

|Professional liability claims |Obtain professional liability claims |X |X | |X |

|history |history through both of the following: |NPDB |NPDB | |NPDB |

| | | | | | |

|Settlements and judgments. |The applicant completing all portions of | | | | |

| |the application. | | | | |

|Current pending claims. |NPDB | | | | |

| | | | | | |

| |180-day rule applies | | | | |

|Continuing medical education |Obtain listing of CME activities for the |X |X | |X |

|(CME) |previous 24 months from applicant. | |More than 50% of CME | |If applicable to new |

| | | |activity should relate | |privilege(s) |

|CME activity should relate to |Note: If applicant completed residency or| |to privileges held. | |requested. For |

|privileges requested/held. |fellowship training (or other | | | |example, CME may be a |

| |professional training for nonphysicians) | | | |requirement for the |

| |within the past two-year period, waive | | | |new privilege(s) |

| |the requirement to submit CME activities | | | |requested. |

| |at the time of initial appointment. | | | | |

| | | | | | |

| |180-day rule applies | | | | |

|National Practitioner Data Bank|NPDB query |X |X | |X |

|(NPDB) | | | | | |

| |180-day rule applies | | | | |

|Medicare/Medicaid and other |Approved method: |X |X | | |

|sanctions | | | | | |

|includes monthly and annual |Applicant provides information and | | | | |

|monitoring |attests to accuracy and completeness. | | | | |

| |and | | | | |

| |NPDB query | | | | |

| |Office of Inspector General | | | | |

| |(oig/cumsan/index.htm) | | | | |

| | | | | | |

| |180-day rule applies | | | | |

|History of criminal conduct |• Applicant provides information and |X | | | |

| |attests to accuracy and completeness. | | | | |

| |and | | | | |

| |• Criminal background check. | | | | |

| | | | | | |

| |180-day rule applies | | | | |

|Peer/Professional References/ |Primary Source via: |X |X | |X |

|Recommendations | |Three letters from |Two letter from peers | |May be applicable and |

| |Letter, copy of requested privileges, and|peers who have had |who have had | |necessary, depending |

|Peer means an individual in the|questionnaire sent directly to |contact with |contact with applicant | |upon the new |

|same professional discipline |peer/professional reference(s). |applicant within |within past two years | |privilege(s) requested|

|(same type of license) with |Questionnaire asks for confirmation of |past two years and |and have personal | |by the applicant |

|essentially the same |applicant’s identify (initial appointment|have personal |knowledge of the | | |

|privileges. |only—based upon enclosed picture of |knowledge of the |applicant's competence | | |

| |applicant). Letters submitted by |applicant's | | | |

| |applicant may not be used. |competence. | | | |

| | | | | | |

| |If telephone inquiries are made, the | | | | |

| |telephone call should be made by an | | | | |

| |official medical staff organization | | | | |

| |representative. | | | | |

| | | | | | |

| |180-day rule applies | | | | |

|Identity of applicant |Approved method: |X | | | |

| | | | | | |

| |A current picture of the applicant must | | | | |

| |be submitted with the initial | | | | |

| |application. A copy of the picture is | | | | |

| |sent to each peer reference, and the peer| | | | |

| |reference is asked to confirm that the | | | | |

| |person for whom they are supplying a | | | | |

| |reference is the same person in the | | | | |

| |picture. | | | | |

| |and | | | | |

| |Before the final recommendation is made | | | | |

| |by the medical executive committee to the| | | | |

| |board, the applicant for initial | | | | |

| |appointment/initial privileges must | | | | |

| |provide his or her government-issued | | | | |

| |identification (driver’s license or U.S. | | | | |

| |passport) and a copy placed in the file. | | | | |

|Clinical activity |Physician to provide documentation from |X | | | |

|Includes clinical activity for |hospital/ambulatory surgery center/office| |X | |X |

|the past 12 months including |setting where he/she has been practicing | |For low volume | |When applicable to |

|(when possible) numbers, types |for the past 12 months. | |practitioners | |demonstrate competency|

|and outcomes of | | | | | |

|procedures/clinical work | | | | | |

|performed. | | | | | |

|PPD |Documentation of results of PPD Test or |X | | | |

| |Chest X-ray |Documentation of |X |X | |

| | |PPD results |Documentation of PPD |Annually | |

| | |completed within |Results or Health | | |

| | |the past year or |Questions completed on | | |

| | |documentation of |Reappointment | | |

| | |Chest X-Ray |Application pertaining | | |

| | | |to any signs/symptoms of| | |

| | | |TB | | |

|Fire and Safety Test |Satisfactory completion of Fire and |X | | | |

|For AHPs only |Safety Test | |X | | |

|Drug Screen |Documentation from drug screen |X | | | |

|For AHPs only | | | | | |

APPROVAL:

Credentials Committee: 3/12/07

MEC: 3/20/07

Board: 3/22/07

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