JEFF ANDERSON REGIONAL MEDICAL CENTER
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Dear Applicant:
Thank you for your interest in medical staff membership at Anderson Regional Medical Center. Enclosed are application forms for membership and privileges. Please return these and include the following:
- small recent photograph (we cannot process your application unless a current photograph
is included)
- copies of current state license to practice
- DEA license showing expiration dates
- copy of social security card and driver’s license
- CV
- copy of Medical Malpractice Policy
- copies of other documents you feel may be pertinent to the Credentials Committee
- signed Physician Acknowledgment Agreement
- signed Electronic Signature Agreement
Your licensure, education, training and previous hospital affiliations will be verified. After all references have been received it will take approximately thirty days to route your credentials through the necessary committees for an evaluation of your qualifications.
As a member of our medical staff, the following information is available for review:
- Medical Staff Bylaws - Corporate Compliance Plan
Anderson Regional Medical Center is committed to providing quality patient care. Compliance with all applicable laws and regulations relative to the Medical Staff will assist us in meeting our commitment. A well organized and functioning medical staff, an effective credentialing and performance improvement process, and Medical Staff Bylaws, Rules and Regulations provide some of the essential components of Anderson Regional Medical Center’s Corporate Compliance Plan.
If you have questions regarding the credentialing procedure you may contact me at 601-553-6306.
Sincerely,
Rhonda Gunn
Credentialing Manager
2124 Fourteenth Street
Meridian, MS 39301
601.553.6306
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PHYSICIAN ACKNOWLEDGMENT STATEMENT
Notice to Physicians: Payment to hospitals by Medicare, Medicaid, and CHAMPUS is based in part on each patient’s principal and secondary diagnoses and the major procedures performed on the patient, as attested to by the patient’s attending physician by virtue of his or her signature in the medical record. Anyone who misrepresents, falsifies or conceals essential information required for payment of federal and state funds may be subject to fine, imprisonment or civil penalty under applicable federal and state laws.
I have read the above notice and acknowledge its receipt.
___________________ _________________________________
Date Physician’s Signature
_________________________________
Physician’s Printed Name
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SIGNATURE LOG
Please record in your own handwriting any and all signatures and initials
by which you may be identified in the hospital medical record.
Legal Name: _____________________________________________________
Credentials (MD, DO, DMD) _______
Legal Signature: __________________________________________________
Variations of Signature: ___________________________________________
___________________________________________
___________________________________________
___________________________________________
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Electronic Signature Statement
Practitioner:______________________________
• The practitioner shall review the document on-line and indicate that it has been reviewed for completeness and accuracy prior to entering a computer code.
• Passwords or other personal identifiers must be controlled carefully by the practitioner in order to provide that only authorized practitioner can apply a specific electronic signature.
• The practitioner shall place in the Administrative Office of the hospital a signed statement to the effect that he/she plans to use electronic signatures for authentication of medical records and he/she will not delegate this function to another individual.
I have received and reviewed the above statement from the Medical Staff Bylaws of Anderson Regional Medical Center and agree to abide by the above mentioned statement concerning electronic signatures
Practitioner Signature:_________________________________________________
Date:_____________________________
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We Want to Keep You Informed
Name: ______________________________________
1. Please let us know your preferred method of contact when the Medical Staff Services Office needs to send you meeting notices and other urgent information.
My preferred method(s) of contact is...
( Office phone #: ______________________________________
( Cell phone: ( Call Cell #: __________________________
( Text
( Email: _____________________________________________
( Other: _____________________________________________
2. Please let us know your preferred method of contact when our pharmacists
need to talk with you about an order.
( Cell phone #: ______________________________________
( Pager #: _________________________________________
3. Please let us know your preferred method of contact when our switchboard
needs to contact you.
( Cell phone #: ______________________________________
( Pager #: _________________________________________
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