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 |
| | | | |
|Institution of Special Training | | | |
LICENSING
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|State License Number |Expiration Date |
PROFESSIONAL LIABILITY INSURANCE (Attach a copy of the Insurance Binder.)
| | | |
|Current Carrier Agent |Limits of Coverage |Effective Dates |
IN THE PAST THREE YEARS:
| | | |
|1. |Have your privileges at a hospital or other health care facility been denied, limited, suspended, non-renewed or | |
| |revoked? |ο Yes ο No |
| | | |
|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 |
| | | |
|3. |Has your license been limited, suspended or revoked in any state? | |
| | |ο Yes ο No |
| | | |
|4. |Have you been placed on probation by any licensing board? |ο Yes ο No |
| | | |
|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 |
| | | |
|6. |Have you ever been sued for medical malpractice? |ο Yes ο No |
| |If yes, are there any claims pending? |ο Yes ο No |
| | | |
|7. |Have you been charged with, or convicted of a felony or misdemeanor, other than traffic violations? |ο Yes ο No |
| | | |
|8. |Have you been treated or hospitalized for any mental or emotional disorders? |ο Yes ο No |
| | | |
|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 |
| |
|If you answered YES to any of these questions, full details are required in writing. |
| | |
|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. |
| | |
|Supervising Physician's Signature |Date |
For Administrative Purposes Only
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| | |
| | |
|Allied Health Professional: |Allied Health Professional: |
| | |
|ο Recommended ο Not Recommended |ο Approved ο Not Approved ο Deferred |
| | |
|_______________________________________ __________ |_______________________________________ _________ |
|Quality Management Committee Chairperson Date |Governing Body Chairperson Date |
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