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INCLUDEPICTURE "" \* MERGEFORMATINET Empire State Medical, Scientific and Educational Foundation, Inc.865 Merrick Avenue, Suite 160(N), Westbury, NY 11590 * 516-437-8134100 Weatheridge Drive, Camillus, New York 13031 * 315-468-2561 * 800-437-2234APPLICATION - CLINICAL REVIEWER*PLEASE PRINT OR TYPE*GENERAL Name:Social Security or Tax ID#: Home Address:City:State:Zip:Home or Cell Phone:Office Address: City:State:Zip:Office Phone #:Fax #:Email:Office Contact Person:Phone #:EDUCATIONCollege/University:Address:City:State:Zip:Degree:Date Received:Medical School:Address:City:State:Zip:Degree:Date Received:TRAININGInternship/Hospital:Address:City:State:Zip:Type of Internship:Date of Internship:Residency/Hospital:Address:City:State:Zip:Type of Residency:Date of Residency:FELLOWSHIPS, PRECEPTORSHIPS, TEACHING APPTS, POSTGRADUATE EDUCATIONList in chronological order – Location, DatesType:Dates:Location:Type:Dates:Location:Type:Dates:Location:Fellowship in other Specialty Colleges:Dates:Fellowship in other Specialty Colleges:Dates:American College of:American College of:LICENSING:State:License Number:Date of License:Expires:State:License Number:Date of License:Expires:State:License Number:Date of License:Expires:Board Certified Specialty:Date Certified:Expires:Board Certified Sub-Specialty:Date Certified:Expires:Board Certified Sub-Specialty:Date Certified:Expires:Drug Enforcement Agency (DEA) Certificate #:Date:Controlled Dangerous Substance Certificate #:Date:Worker’s Compensation Certification #/Rating:Date:PLACE AN “X” IN ALL SETTINGS IN WHICH YOU PRACTICE (Must be in active practice):_____Inpatient: Acute Care Hospital and/or Distinct-Part Units_____Hospital Outpatient Unit/Facility_____Hospital Ambulatory Surgery Unit_____Skilled Nursing Facility (SNF)_____Private Practice_____Other (Please specify):Indicate length of time (include dates) providing direct patient care:Are you currently Utilization Review certified with the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP)?: Yes_____ No_____If “Yes”, indicate date Certified and date certification expires:UTILIZATION REVIEW EXPERIENCE, QUALITY ASSURANCE ACTIVITY, CHART REVIEW EXPERIENCE:Do you have experience in utilization review or quality assurance review activities? ____Yes ____No If yes, how many years’ experience? _______TO AVOID ANY POTENTIAL CONFLICT OF INTEREST, IT IS IMPORTANT THAT INFORMATION REQUESTED BELOW BE PROVIDED. THE FOUNDATION MUST ENSURE THAT YOU ARE NOT ASKED TO REVIEW CASES INVOLVING ANY PARTY YOU ARE AFFILIATED WITH.LIST ALL HOSPITALS/FACILITIES WHERE YOU HAVE STAFF PRIVILEGES AND/OR AFFILIATIONS:Name/LocationPositionDatesLIST ALL INSURANCE COMPANIES/HEALTH PLANS FOR WHICH YOU PERFORM MEDICAL REVIEW AND/OR ARE UNDER CONTRACT WITH TO PROVIDE HEALTH CARE SERVICES:Name/LocationPositionDatesIF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS “YES”, PLEASE GIVE FULL DETAILS ON A SEPARATE SHEET OF PAPER. (Please circle “YES” or “NO”)YESNOHas your license to practice medicine, dentistry or any other profession in any jurisdiction ever been or is it in the process of being denied, not renewed or voluntarily relinquished, suspended or revoked?YESNOHas your membership status and/or clinical privileges ever been or is it in the process of being suspended, diminished, revoked or not renewed at any hospital or institution?YESNOHave you ever been denied membership or renewal thereof, on a hospital medical staff or are you currently being recommended for denial of membership or renewal thereof?YESNOHas your request for any specific clinical privileges ever been denied or granted with stated limitations?YESNOHave you ever been subject to disciplinary action or sanctions in any medical or dental organization, or are you currently the subject of any disciplinary action or sanction?YESNOHave you ever been charged with and/or found guilty of professional misconduct as defined in the Education Law of the State of New York or unprofessional conduct as defined by the Board of Regents?YESNOHas your membership in Local, State or National Medical Societies ever been or is it in the process of being suspended or terminated?YESNOHas your DEA or CDS certificate ever been or is it in the process of being suspended or revoked?YESNOExcept for minor traffic violations, have you ever been convicted of committing an act constituting a crime under NYS law, Federal law, or the law of another jurisdiction which, if committed within this State, would have constituted a crime under NYS law?YESNOHave you ever been named in a malpractice suit? If “YES” please give full details including: What were the issues involved? Are they still pending? Or have they been resolved? What was the outcome?I HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS CORRECT. I AGREE TO NOTIFY THE FOUNDATION IMMEDIATELY SHOULD THERE BE ANY CHANGES IN MY ADDRESS, CREDENTIAL STATUS, SANCTIONS AGAINST THE CREDENTIAL, CHANGE IN LICENSURE OR CHANGE IN HOSPITAL OR HEALTH PLAN HOSPITAL AFFILIATION(S).______________________________________________________________________Signature of ApplicantDatePlease indicate the number of hours per week that you are interested in performing consultant review:_______________Are you willing to come to our office to perform the review(s) (we are open Monday-Friday 8:30-4:30 p.m.)?: YESNOIN OUR DOWNSTATE REGION OFFICE – Westbury, NY865 Merrick Ave, Suite 160 N, Westbury, New York 11590YESNOIN OUR UPSTATE REGION OFFICE – Camillus, NY 100 Weatheridge Drive, Camillus, NY 13031 (Syracuse suburb)YESNOIf unavailable to come to our office, are you willing to pick up and return the reviews (within 5 days) to the respective local area office?YESNOIf unavailable to come to our office, are you interested in receiving the chart reviews via the express delivery service to your home or office (a signature is required)? (If YES, indicate the address to which deliveries will be sent. Be sure to include a daytime phone number in the event that the delivery service experiences any difficulties attempting delivery.)Delivery Address:____________________________________________________________City:__________________________________________ State_______ Zip_____________Daytime Phone #:________________________________Some available to sign for package? Yes_____ No_____YESNOSome reviews must be completed within 24 hours of receipt of the documentation. The documentation may be faxed to your office, or sent to you via secure email, and/or you may be required to speak to the treating physician. (This is an occasional review.) Do you agree to participate?YESNOI have enclosed a copy of my curriculum vitae? (See attached.)YESNOI have enclosed additional documentation to supplement the information contained in this application? (Please list the attachments below)ESMSEF Use Only1. Date application mailed to physician:2. Date application received back from physician: 3. Date additional information requested from physician: 4. Date additional information received from physician: 5. Date information ruled complete: 6. Date referred to Medical Director: 7. Decision of Medical Director: _____Approve _____Deny Date: ____________________8. Medical Director/Assist Medical Director Signature: 9: If not approved, please state reason: 10. Date verification process complete ():11. Date credentialing complete (profileservice.):12. Date acceptance letter mailed to physician: 13. Date rejection letter mailed to physician:Notes:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
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