Helena SurgiCenter, LLC



Helena SurgiCenter, LLC

ALLIED HEALTH PROFESSIONAL STUDENT APPLICATION

IDENTIFYING INFORMATION

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|Last Name First Middle |Social Security Number |

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|Office Address |City/State/Zip |Office Telephone |

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|Home Address |City/State/Zip |Home Telephone |

EDUCATION

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|College or University |City/State |Date of Graduation |Degree |

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|Institution of Special Training | | | |

LICENSING

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|State License Number |Expiration Date |

PROFESSIONAL LIABILITY INSURANCE (Attach a copy of the Insurance Binder.)

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|Current Carrier Agent |Limits of Coverage |Effective Dates |

IN THE PAST THREE YEARS:

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|1. |Have your privileges at a hospital or other health care facility been denied, limited, suspended, non-renewed or | |

| |revoked? |ο Yes ο No |

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|2. |Have you been involved in proceedings brought by a hospital or other health care facility to deny, limit, suspend,| |

| |non-renew or revoke your privileges. |ο Yes ο No |

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|3. |Has your license been limited, suspended or revoked in any state? | |

| | |ο Yes ο No |

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|4. |Have you been placed on probation by any licensing board? |ο Yes ο No |

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|5. |Have you been notified to respond to or appear before any licensing or regulatory agency on a complaint of any | |

| |nature, including, but not limited to, unprofessional or unethical conduct? |ο Yes ο No |

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|6. |Have you ever been sued for medical malpractice? |ο Yes ο No |

| |If yes, are there any claims pending? |ο Yes ο No |

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|7. |Have you been charged with, or convicted of a felony or misdemeanor, other than traffic violations? |ο Yes ο No |

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|8. |Have you been treated or hospitalized for any mental or emotional disorders? |ο Yes ο No |

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|9. |Have you been treated or hospitalized for use of any of the following: | |

| |Alcohol |ο Yes ο No |

| |Narcotics |ο Yes ο No |

| |Central nervous system stimulants or depressants |ο Yes ο No |

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|If you answered YES to any of these questions, full details are required in writing. |

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|To the best of my knowledge, the above statements are the truth and | |

|I have not knowingly withheld any information. |Signature |

In making this application for approval as An Allied Health Professional Student, I agree to abide by Facility policies and procedures. I fully understand that my authorized activities will be strictly delineated by the Medical Staff and by my supervising physician. I will promptly notify the HSC Administration and my supervising physician of any change in my status as it has been reported on this form.

In completing this application, I fully realize that I am not applying for membership in the Medical Staff of this facility and that I will not be entitled to the legal right of due process afforded under the Medical Staff Bylaws. Furthermore, I understand that my authorized activities may be terminated or suspended at any time at the discretion of the supervising physician, the Medical Director and/or the Governing Body.

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|Applicant's Signature |Date |

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|STATEMENT OF RESPONSIBILITY FOR ALLIED HEALTH PROFESSIONAL |

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|I hereby agree to accept total responsibility of the Allied Health Professional while supervising. I also attest to the fact that an |

|adequate investigation of the Affiliate's qualifications and character has been performed and that the individual, in my opinion, is |

|capable of performing requested privileges. |

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|Supervising Physician's Signature |Date |

For Administrative Purposes Only

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|Allied Health Professional: |Allied Health Professional: |

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|ο Recommended ο Not Recommended |ο Approved ο Not Approved ο Deferred |

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|_______________________________________ __________ |_______________________________________ _________ |

|Quality Management Committee Chairperson Date |Governing Body Chairperson Date |

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