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APPLICATION FOR REAPPOINTMENT

PART TWO

UNIVERSITY HEALTHCARE SYSTEMS APPLICATION FORM

NAME (PLEASE PRINT):

|SPECIALTY: | |

| |

|STAFF CATEGORY (Please check one box): |

| Active ( | Courtesy ( | Podiatric ( |Consulting ( |Associate ( |

| |

|DEMOGRAPHIC/PRACTICE INFORMATION: |

|Office Address: |Home Address: |

|Office Phone | |Home Phone | |

|Office Fax | |E-mail address | |

|Organization Name: |

|Organization Web Address (If Applicable): |

| |

|OFFICE MANAGER: |

|Phone Number: |Fax Number: |

|Email Address: |

|CREDENTIALING COORDINATOR: |

|Phone Number: | Fax Number |

|Email Address: |

|CLINICAL PRIVILEGE DELINEATION |

|This section MUST be completed by the APPLICANT |

| (Associate Staff Members omit this section) |

| |I have reviewed current clinical privileges granted; I have reviewed volume (V) required privileges if applicable. |

| |I have reviewed the Physician Profile’s Procedures Performed Report. |

| |Requesting renewal of privileges at: |

| |University Hospital-Augusta |

| |University Hospital-McDuffie |

| |Both |

| |Request nonrenewal of the following privileges (please attach-Applicant should especially review low volume procedures outside of his/her core) |

| |Request extension of privileges for ______________ |

| |No changes requested |

|I have personally reviewed and completed the above. |

| |

|Date________________________________________ Signature_____________________________ |

| |

| |

|CME ATTESTATION |

|DO NOT SUBMIT COPIES OF CME CERTIFICATES |

|Physicians who are lifetime boarded are required to satisfactorily complete at least 60 hours of Category I C.M.E. every two years related to their primary |

|practice specialty. Physicians who are not lifetime boarded are required to submit 40 hours of C.M.E. every two years related to their primary practice specialty.|

|I hereby certify that within the past two year reappointment period, I have completed the required number of hours of continuing medical education credits. If |

|audited I will be able to provide documentation of seminars and/or courses attended. I recognize that failure to produce documentation upon request will |

|jeopardize my Medical Staff membership. |

| |

|____________ ___________________________________ |

|Date Signature |

|CALL COVERAGE |

|Please list current call partners (If necessary, attach separate list) |

| 1. |3. |

|2. |4. |

|HOSPITAL AFFILIATIONS |

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

| |3 |

|2. |4. |

|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. Answering yes will NOT |

|necessarily disqualify you from the Medical Staff. |

|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 two (2) years? |

| | |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 |

|List the name and address of two (2) peers MD,DO,DPM (one must be an individual in the same professional field, preferably the same department or specialty) |

|excluding the Division, Section or Department Chief, who has direct knowledge of your clinical abilities. |

|Name/Address | |

| | |

| | |

| | |

| | |

|Name/Address: | |

| | |

| | |

| | |

| | |

|BYLAWS AND RULES AND REGULATIONS ATTESTATION |

| |

|In making application for appointment to the Medical Staff of University Hospital, I acknowledge that I have received and read the Medical Staff Bylaws and Rules|

|and Regulation, and I agree to be bound by the terms of all such bylaws and rules and regulations and initial credentialing policy as are in force during the |

|time I am appointed or reappointed to the Medical Staff or exercise clinical privileges 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 that until I receive written approval of my new effective appointment date by the hospital CEO or the Board of Directors, I |

|will not provide any patient services at University Healthcare System beyond my current appointment.. |

| |

| |

| |

|_________________ __________________________________________________________ |

|Date Signature |

REFLEX TESTING ACKNOWLEDGMENT

PURPOSE:

The purpose of this Reflex Testing acknowledgment is to ensure that our physicians understand when reflex tests will be performed and how they will be billed to Medicare.

POLICY:

University Health Care System Hospital’s Laboratory will automatically perform reflex tests according to the criteria in the attached list when all three of the following conditions are met, unless your order specifically states that you do not want the reflex test performed:

1. An initial test has been performed as ordered;

2. The initial test result meets the criteria for the reflex test; and

3. The Hospital’s Medical Executive Committee has approved those tests and criteria.

BILLING OF REFLEX TESTS:

The Hospital bills for medically necessary reflex tests according to the CPT code listed on the attachment. The Medicare fee schedule amount is listed with each CPT code.

ACKNOWLEDGMENT AND APPROVAL:

By signing this acknowledgment, you acknowledge that you have reviewed the attachment and agree that, whenever the initial test ordered meets the reflex criteria, the corresponding reflex test will be performed, reported and billed.

If in the case of an individual patient, you consider the reflex test unnecessary, you must order the initial test without the reflex. With the exception of those tests required by law, you may order any test without the reflex option.

We recommend that you utilize the Hospital laboratory requisition in order to clearly indicate the tests that you want performed.

This acknowledgement may be terminated at any time with written notice to the Laboratory Director.

Contact Person: Laboratory Director

Facility Address: 1350 Walton Way, Augusta, GA 30901-2629

Phone: 706-774-5400

Email: CPardue@

Notification of any additions or modifications to reflex tests will be communicated via the Notification of Additions or Modifications for Reflex Testing form as they are approved by the Medical Executive Committee.

Physician Signature: Date:

|Lab Dept. |Test Name |Reflex test |

|Core Lab |Hepatitis C Virus Antibody |HCV RNA Quantiative Real-Time PCR added if repeatly reactive |

| |Urinalysis |Microscopic exam added if positive |

| |Urine Drug Screen |Drug Confirmation added for each drug that is positive |

| |Acetone |Titer added if positive |

| |Hepatitis B Surface Antigen |HBSAG confirmation added if reactive |

| |HIV Screen |Western Blot confirmation added if reactive |

| | | |

|Reference Lab |Smooth Muscle Antibody |Titer if positive |

| |Gluten Evaluation: Endomysial IgA |Titer if positive |

| |Gluten Evaluation: Reticulin IgA |Titer if positive |

| |Hemoglobin Electrophoresis Profile |Quantitation performed if abnormal |

| |Viral Encephalitis Profile |HSV 1 & 2 Glycoprotein G-Specific, IgG added if HSV is positive |

| |Streptozyme Screen |Titer if positive |

| |Striated Muscle Antibody Screen |Titer if positive |

| |HSV 1/2 Ab, G and M |Type 1 or 2 Glycoprotein G-Specific IgG added if postive |

| |Myasthenia Gravis Panel |Striated Muscle Ab Titer added if Striated Muscle Screen is |

| | |positive |

| |Dilute Russell Viper Venom Test |Russell Viper Venom 1:1 Mix, added if prolonged; Confirmation |

| | |added if 1:1 mix is prolonged |

| |Drug Screen - Serum or Plasma |Drug Confirmation added for each drug that is positive |

| |Tissue Transglutaminase - IgA |Titer if positive |

| |VDRL - CSF |Titer if reactive |

| |Heavy Metal Panel - Urine |Arsenic Fractionation added if Arsenic is elevated |

| |Human T-Cell Leukemia Antibody |Western Blot added if positive |

| |Myeloperoxidase Ab |Titer added if positive |

| |Serine Protease 3, IgG |Titer added if positive |

| |Factor V Leiden |Not a screening test. Orders will be converted to Factor V APC |

| | |resistance with positive reflex to Factor V Leiden |

| | | |

|Infectious Disease |RPR |Titer & FTA added if reactive |

| |Antinuclear Antibody |Titer added if positive |

| |DNA Antibody Screen |Titer added if positive |

| |Extractable Nuclear Ag Profile |Titer added if positive for each Antibody (SM and/or RNP) |

| |Cryptococcal Antigen CSF |Titer added if positive |

| | | |

|Pathology |Surgical Pathology Specimens |Immunoperoxidase, Special Stains, or Recuts added |

| |Flow Cytometry |Additional Markers added per pathologist for diagnostic purposes |

|Blood Bank |Antibody Screen |Ab Identification if positive screen, Autocontrol, Antigen Type |

| | |for Compatible Blood |

| |Antibody Screen on OB Patients |Antibody Identification and Titer if positive screen |

| |Direct Coombs on Cord Blood |Cord Blood Bilirubin added if positive |

| |Direct Coombs |Possible Elution added if positive per protocol/history |

| |Autocontrol |Direct Coombs added if positive, possible elution also added |

| |Rh Negative females(= or 5) Physician Overide Protocol is avalable upon |

| | |request |

| |Blood Cultures (New 2017) |If positive will reflex to Accelerate Pheno (FISH) testing for |

| | |rapid ID and sensitivity with continued follow through of |

| | |traditional Micro testing as well. |

Physician Satisfaction Assessment

**Please rate your satisfaction of 1-5 with 1 being not at all and 5 representing all the time.

| |Not at all |Rarely |Sometime3 |Most of |All the time |

| |1 |2 | |the time |5 |

| | | | |4 | |

|My patients are admitted in an efficient and timely manner. | | | | | |

|Communication from Nursing services concerning my patients is timely,| | | | | |

|pertinent and clear. | | | | | |

|Scheduling of procedures, i.e., (Lab/radiology) is easy, efficient | | | | | |

|and timely. | | | | | |

|The hospital has appropriate equipment to provide care for my | | | | | |

|patients. | | | | | |

|Epic is a useful tool in obtaining clinical data for patient care. | | | | | |

|The CME Office provides lectures that meet my educational needs. | | | | | |

|HIS/CVP dictations are transcribed in a timely manner. | | | | | |

|When I present an issue to Case Management, I feel that I am taken | | | | | |

|seriously and adequate steps are taken to meet my expectations, or if| | | | | |

|actions cannot be taken I am informed in a timely manner. | | | | | |

|My overall experience of working in the hospital and the caring of my| | | | | |

|patients is excellent. | | | | | |

|The Clinical Documentation Specialists provide me with the necessary | | | | | |

|tools and resources to improve my documentation accuracy, severity of| | | | | |

|illness and risk of mortality. | | | | | |

|If any of your responses to numbers 1 – 10 were not rated a 4 or 5, what could we do differently to meet or exceed your expectations? |

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| |

|What one thing would you suggest to improve the organization to better serve your needs and the needs of your patients? |

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|If you prefer another method of communication other than the current fax system, (i.e., phone, e-mail, text messaging, etc.) please indicate|

|below: |

| |

| |

Please make sure you return your Physician Satisfaction Assessment at the same time of reappointment application.

INFORMATION ONLY

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.

Restraints and Seclusion Policy

General Restraint Definition - A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.

Purpose – Define a safe, effective approach to protecting the safety of the patient and others when less restrictive measures are not effective or appropriate, an approach that provides compliance with regulatory parameters.

Types of restraint and seclusion

• Non-violent – for safety’s sake to prevent pulling out IV lines or devices or inability to follow instructions, such as about climbing out of bed.

• Violent or self-destructive – requiring physical or chemicals to address aggressive behavior toward self or others

• Seclusion – (Limited to the ED on Main campus) – involuntary confinement to manage violent or self-destructive behavior

• Chemical restraint – use of a medication for controlling behavior that is not part of the standard or usual treatment for the patient’s condition

Orders for restraints

• The elements for satisfying regulatory compliance are built into the standard orders

• Screen shots of both Non-violent and Violent restraints are attached

• Coordination of care with the Nursing staff, to include the requirements regarding seeing the patient and reordering of restraints, are embedded in the orders.

• Following these requirements increases the likelihood that the application of restraints will safely meet the clinical situation.

I acknowledge that I understand the types of restraints and the regulatory expectation to comply will use the standard order sets, and work with the nursing staff in managing restrained patients safely.

______________________________ ________________________ ___________

Signature Printed Name Date

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