UNIVERSITY HOSPITAL



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PART TWO

ALLIED HEALTH PRACTITIONER REAPPOINTMENT APPLICATION

|BIOGRAPHICAL INFORMATION |

|Name (Please Print): |SS Number: |

|Office Address: |Home Address: |

|Office Phone: |Home Phone: |

|Office Fax: |E-mail: |

|HOSPITAL AFFILIATIONS |

|Please list current affiliations where you have membership (If necessary, attach separate list) |

| |4. |

|2. |5. |

|3. |6. |

|HEALTH STATUS |

| Check appropriate column. If you answer yes to any of these questions, please provide the details on the explanation page in Part I. |

|Yes |No |Questions: |

| | |Have you been hospitalized at any time since your last application? |

| | |Do you have symptoms of weight loss, cough, fever or night sweats |

| | |Have you had a PPD skin test within the past year? |

| | |Do you have a history of a positive PPD? If yes, list date_____________ |

| | |Have you received prophylactic isoniazid? If yes, duration: date: ___________ |

| | |Have you had a negative chest x-ray? If yes, when ____________________ |

|PEER REFERENCES |

|Please provide the names of two-peer references who can attest to your current competence. At least one of the references must have the same or similar training|

|(R.N. to R.N., PA to PA, etc.) as you. |

|1. Name/Address: | |

| | |

|2. Name/Address: | |

| | |

|SUPERVISING PHYSICIAN |

|Please list current supervising physician(s) below: |

| |

|SPONSORING PHYSICIAN FOR CURRENT COMPETENCY |

|Please list current sponsoring physician(s) for current competency below: |

| |

|CLINICAL PRIVILEGE DELINEATION |

|Please review your current clinical privileges attached with reappointment letter. |

| |No changes requested. |

| |Request an extension of privileges. (list on explanation page) |

| |Request to relinquish privileges listed: |

| |(list on explanation page) |

| |Requesting renewal of privileges at: |

| | |

| |University Hospital-Augusta |

| |University Hospital-McDuffie |

| |Both |

|I have personally reviewed and completed the above. |

| |

|Date________________________________________ Signature_____________________________ |

|ATTESTATION STATEMENT |

| |

|In making application for appointment as an Allied Health Professional to University Hospital, I acknowledge that I have received and read the Allied Health |

|Professional Policy, and I agree to be bound by the terms of the policy in force during the time I am appointed or reappointed as an Allied Health Professional |

|at University Hospital. I understand that information so provided is protected under GA law 31-7-130 et sq and under 42 USC 111,111 et sq (The Federal Health |

|Care Improvement Act), I acknowledge and agree that the Hospital has elected treatment as an Organized Health Care Arrangement (OHCA) under the patient privacy |

|regulations adopted under the Health Insurance Portability and Accountability Act of 1996(“HIPAA”). |

|By signing this attestation, I agree to have my sponsoring physician (s) receive updates on the status of my application as well as, receipt of information |

|regarding my approval and effective appointment date |

| |

|Furthermore, by signing this attestation, I agree that until I receive written approval of my effective appointment date by the hospital CEO or the Board of |

|Directors, I will not provide any patient services at University Hospital. |

| |

| |

| |

|Applicant’s Signature Date |

| |

UNIVERSITY HOSPITAL

CONFIDENTIALITY STATEMENT

During my training, observation or other experience at University Hospital (the Hospital), I, the undersigned, understand that I may encounter data that contains protected patient health information, employee or other sensitive information. I understand that all data and information of the Hospital are used to provide services and that the trust of patients, medical staff and the organization is vested in me to treat that information as confidential. I understand that I am not to disclose any data or information without seeking guidance from the policies of the Hospital and the policies and procedures of the department governing systems to which I have access. I understand that the Medical Record and other hospital data and information are property of the Hospital; the information contained within the medical record belongs to the patient.

By signing this statement, I hereby agree to conform to Hospital, departmental, and systems policies and procedures. I understand that both Federal and State laws apply to some incidences of release of information and that violation of system(s), departmental, and/or hospital policies and procedures may also be violation of these laws. I accept complete responsibility for my own actions and I understand that if at any time I violate these guidelines, I am subject to immediate termination of employment at University Hospital and/or legal action. I indicate my understanding of the content of this statement and acknowledge receipt of a copy by my signature below.

Printed Name

_______________________________________ ____________________

Signature Date

_______________________________________ ____________________

Witness Date

Health Care Professional Impairment

This information on Health Care Professional Impairment is devoted to helping the medical staff and allied health professionals become more knowledgeable about impairment. Patient safety is our overriding principle. For health care professionals to provide safe care, they must be able to think clearly, assess clinical situations accurately, and act in the best interest of the patient. Impairment, no matter what the cause, leads to unsafe decisions and therefore, jeopardizes patient care.

What is impairment?

Health care professional impairment exists when the health care professional cannot effectively perform the duties of the job. Most often impairment is due to drug or alcohol use or abuse, but it can also be caused by emotional, mental or even physical illnesses. The prevalence of impairment among health care professionals is slightly lower than among other professionals and is about the same as in the general population.

Chronic impairment due to drug and alcohol abuse can be successfully treated if recognized and treated early. Even though some chronic and degenerative diseases such as Alzheimer’ worsen over time, their progression might be slowed with treatment.

Practitioner Assistance Committee (PAC)

University Hospital’s Medical Staff has established a PAC to provide education and support to a practitioner affected by any physical, emotional, psychiatric impairment, or potential impairment, involving, among other conditions, alcohol and drug abuse, psychiatric disability, physical impairment, problems of aging, sexual misconduct, and the distress of everyday medical practice. The PAC will provide assistance and monitoring to enable a practitioner to gain restoration of optimal functioning rather than initiating disciplinary action.

What should I do if impairment is suspected?

Any hospital personnel, allied health professional or physician concerned about a practitioner’s condition and ability to function professionally may contact either the department chairman

of the appropriate department or the President of the medical staff At this time, the practitioner may be referred to the PAC. A practitioner may also refer himself/herself to the committee.

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