CREDENTIALS OF EMERGENCY DEPARTMENT PHYSICIANS



List 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 CriteriaExp.orMOCExp.DateCourseCompletionExp.Date# of HRS of Pediatric Emergency related CME(16 HRS/past 2 years required)APLSPALS1Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.2Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.3Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.4Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.5Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.6Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.7Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.8Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.9Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.10Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.Click here to enter text.Click here to enter text.SignatureTyped NameDateHospital CEO/AdministratorHospital CEO/Administrator(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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 CriteriaExp.orMOCExp.DateCourseCompletionExp.Date# of HRS of Pediatric Emergency related CME(16 HRS/past 2 years required)APLSPALS11Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.12Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.13Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.14Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.15Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.16Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.17Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.18Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.19Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.20Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.Click here to enter text.Click here to enter text.SignatureTyped NameDateHospital CEO/AdministratorHospital CEO/Administrator(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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 CriteriaExp.orMOCExp.DateCourseCompletionExp.Date# of HRS of Pediatric Emergency related CME(16 HRS/past 2 years required)APLSPALS21Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.22Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.23Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.24Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.25Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.26Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.27Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.28Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.29Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.30Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.Click here to enter text.Click here to enter text.SignatureTyped NameDateHospital CEO/AdministratorHospital CEO/Administrator(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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 CriteriaExp.orMOCExp.DateCourseCompletionExp.Date# of HRS of Pediatric Emergency related CME(16 HRS/past 2 years required)APLSPALS31Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.32Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.33Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.34Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.35Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.36Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.37Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.38Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.39Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.40Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.Click here to enter text.Click here to enter text.SignatureTyped NameDateHospital CEO/AdministratorHospital CEO/Administrator(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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 CriteriaExp.orMOCExp.DateCourseCompletionExp.Date# of HRS of Pediatric Emergency related CME(16 HRS/past 2 years required)APLSPALS41Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.42Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.43Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.44Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.45Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.46Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.47Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.48Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.49Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.50Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.Click here to enter text.Click here to enter text.SignatureTyped NameDateHospital CEO/AdministratorHospital CEO/Administrator(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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 CriteriaExp.orMOCExp.DateCourseCompletionExp.Date# of HRS of Pediatric Emergency related CME(16 HRS/past 2 years required)APLSPALS51Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.52Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.53Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.54Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.55Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.56Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.57Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.58Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.59Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.60Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.Click here to enter text.Click here to enter text.SignatureTyped NameDateHospital CEO/AdministratorHospital CEO/Administrator(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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 CriteriaExp.orMOCExp.DateCourseCompletionExp.Date# of HRS of Pediatric Emergency related CME(16 HRS/past 2 years required)APLSPALS61Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.62Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.63Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.64Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.65Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.66Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.67Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.68Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.69Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.70Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.Click here to enter text.Click here to enter text.SignatureTyped NameDateHospital CEO/AdministratorHospital CEO/Administrator(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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 CriteriaExp.orMOCExp.DateCourseCompletionExp.Date# of HRS of Pediatric Emergency related CME(16 HRS/past 2 years required)APLSPALS71Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.72Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.73Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.74Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.75Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.76Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.77Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.78Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.79Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.80Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.Click here to enter text.Click here to enter text.SignatureTyped NameDateHospital CEO/AdministratorHospital CEO/Administrator(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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 CriteriaExp.orMOCExp.DateCourseCompletionExp.Date# of HRS of Pediatric Emergency related CME(16 HRS/past 2 years required)APLSPALS81Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.82Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.83Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.84Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.85Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.86Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.87Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.88Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.89Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.90Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.Click here to enter text.Click here to enter text.SignatureTyped NameDateHospital CEO/AdministratorHospital CEO/Administrator(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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 CriteriaExp.orMOCExp.DateCourseCompletionExp.Date# of HRS of Pediatric Emergency related CME(16 HRS/past 2 years required)APLSPALS91Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.92Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.93Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.94Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.95Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.96Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.97Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.98Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.99Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.100Click here to enter text.F/PDateClick here to enter text.Date??DateClick here to enter text.Click here to enter text.Click here to enter text.SignatureTyped NameDateHospital CEO/AdministratorHospital CEO/Administrator(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.) ................
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