CREDENTIALS OF EMERGENCY DEPARTMENT PHYSICIANS



List 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)APLSPALSENPC1Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText2Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText3Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText4Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText5Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText6Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText7Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText8Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText9Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText10Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextTextClick here to enter text.DateSignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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)APLSPALSENPC11Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText12Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText13Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText14Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText15Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText16Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText17Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText18Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText19Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText20Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextTextClick here to enter text.DateSignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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)APLSPALSENPC21Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText22Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText23Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText24Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText25Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText26Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText27Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText28Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText29Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText30Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextTextClick here to enter text.DateSignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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)APLSPALSENPC31Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText32Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText33Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText34Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText35Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText36Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText37Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText38Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText39Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText40Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextTextClick here to enter text.DateSignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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)APLSPALSENPC41Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText42Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText43Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText44Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText45Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText46Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText47Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText48Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText49Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText50Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextTextClick here to enter text.DateSignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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)APLSPALSENPC51Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText52Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText53Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText54Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText55Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText56Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText57Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText58Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText59Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText60Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextTextClick here to enter text.DateSignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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)APLSPALSENPC61Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText62Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText63Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText64Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText65Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText66Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText67Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText68Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText69Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText70Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextTextClick here to enter text.DateSignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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)APLSPALSENPC71Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText72Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText73Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText74Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText75Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText76Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText77Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText78Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText79Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText80Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextTextClick here to enter text.DateSignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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)APLSPALSENPC81Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText82Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText83Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText84Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText85Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText86Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText87Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText88Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText89Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText90Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextTextClick here to enter text.DateSignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.)List 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)APLSPALSENPC91Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText92Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText93Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText94Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText95Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText96Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText97Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText98Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText99Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextText100Click here to enter text.ED/FTDate?TextTextDateText???DateClick here to enter text.TextTextClick here to enter text.DateSignatureHospital CEO AdministratorTyped NameHospital CEO/AdministratorDate(Note: The signature of the Hospital CEO/Administrator verifies that all information is current and accurate.) ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download