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MAJESTY CARE CLINIC
VOLUNTEER APPLICATION FOR
INDEPENDENT PRACTITIONERS (MD, CRNP, PA etc.) 2015
Phone: 724.691.0216 Fax: 724.691.0416
Please type or print with black or blue ink. PRIVATE FOR OFFICE USE ONLY
Check One: _____ Physician _____ Certified Registered Nurse Practitioner _____ Physician Assistant _____ Other
Applicant Name ___________________________________________________________________________________________
First Middle Last
Mailing Address __________________________________________________________________________________________
Provide phone numbers: Cell _____________________________________________ Gender ______ Male ______ Female
Office ___________________________________________ Home _____________________________________________
Email ____________________________________________________________________
Date of Birth __________________________________________ SS# _______________________________________________
Emergency Contact Person _________________________________________________________________________________
Phone Number(s) _________________________________________________________________________________
How did you hear about MCC? _______________________________________________________________________________
Are you a U.S. citizen? _____ yes _____ no If no, do you have authorization to work in the US? _____ yes _____ no
Undergraduate Education
College(s) Attended ________________________________________________________________________________________
Address of College(s) ______________________________________________________________________________________
Year of Graduation _______________ Degree(s) _______________________________________________________________
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Check one _____Residency _____ Fellowship _____ Internship or Name Other Training_____________________________
And Provide Program/Institution Name ________________________________________________________________________
Address __________________________________________________________________________________________________
Year of Graduation ______________ Specialty __________________________________________________________________
Board Certified? _____ Yes _____ No Date of Expiration ____________________________________________________
Fellowship Training (if applicable) ____________________________________________________________________________
Date of Fellowship Training ___________________________
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These numbers are necessary and important. Write NONE if applicable. Also, please attach a copy of your current license.
License # _______________________Expiration Date: ________________ Type/Specialty ______________________________
NPI# ________________________________ Federal DEA Reg. Number(s) _______________________________________
Medicare Provider Number ________________________ Medicaid Provider Number __________________________________
Primary Hospital Affiliation is with ____________________________________________________________________________
Do you have admitting privileges with the hospital? _____ Yes or _____ No
If you answer “YES” to any of the following, briefly explain the case and outcome on an additional sheet and attach it.
Any malpractice claims against you currently or in the past 10 years? _____ Yes _____ No
Do you have any claims that remain ongoing? _____ Yes _____ No
Has your license ever been revoked or suspended for any reason? _____ Yes _____ No
Have you ever been convicted of a crime? _____ Yes _____ No
Are you currently using illegal substances or illegally using substances? _____ Yes _____ No
Employment History
Current Employer ________________________________________________________________________________________
Address _________________________________________________________________________________________________
Employer’s Work Phone ___________________________________ What date did you begin? _________________________
Previous Employer Town/State Dates (from/to)
_____________________________________________ ________________________ _________/_________
CPR _____ Yes _____ No I have a current CPR certification? Provide a copy of your certificate.
Immunization Status _____ Yes _____ No I have a current TB (PPD) Test.
If Yes, please include a copy of the test results which must be within 1 year. There is a
form to complete if you had a positive reaction or cannot take the test.
Photo Id Please include a copy of your driver’s license or other government issued photo ID.
Background Clearances All volunteers are required to submit a Criminal Background Check.
_____ Yes, I have a current (within the last 2 yrs) criminal background check. Please include a
CHECK ONE: copy.
_____ No, I do not have a current criminal background check and authorize MCC or Excela
Health to obtain one.
MALPRACTICE INSURANCE
1. _____ Yes _____ No I desire to volunteer at MCC and provide services to treat patients.
2. _____ Yes _____ No My malpractice insurance DOES NOT insure me to volunteer and treat patients at Majesty Care
Clinic and I am requesting to be “deemed” by HRSA to acquire free malpractice insurance
through the FTCA and authorize MCC and or Excela Health to apply for me.
3. _____ Yes _____ No I understand and agree that Excela Health will act as the CVO (Credential Verification
Organization) for MCC and as such they will verify the accuracy and correctness of my
credentials.
4. Check ONE:
_____ I am affiliated with Excela Health and I authorize and give permission for Excela Health to
release my records pertaining to the information requested in this application and for the
purpose of volunteering at MCC.
OR
_____ I am not affiliated with Excela Health. I agree to provide my credentialing information in order
that Excela Health may verify my credentials and certify their accuracy for MCC upon request.
**** Complete only if your malpractice insurance insures you to volunteer at MCC and you do not want the free malpractice
insurance through HRSA and the FTCA. Providers should not be insured by two carriers for work at MCC.
If malpractice is through a hospital, please provide the name. My malpractice insurance carrier is _____________________
My insurance carrier’s phone # is _______________________ and my policy # is _____________________________________
Dates of Coverage: From _____/_____/_____ To _____/_____/_____ Contact Person ______________________________
Who holds the Certificate of Insurance? _____ Self _____ Practice _____ Hospital _____ Other____________________
ADDITIONAL CONFIDENTIAL INFORAMTION
If you have any “yes” answers to any questions below, submit a separate sheet providing full details for each item.
Have any of the following at any time been, or are they currently in the process of being denied, revoked, not renewed, suspended, limited, restricted, placed on probation, or placed under other disciplinary action, either voluntarily or involuntarily in any jurisdiction?
YES NO
Medical or professional license _____ _____
DEA _____ _____
Hospital medical staff membership _____ _____
Clinical privileges or other rights on any hospital medical staff _____ _____
Employment by any hospital, institution, or the military _____ _____
Professional society memberships _____ _____
Participation in any private, federal, or state health insurance program _____ _____
Participation in an HMO, PPO, or any other managed care organization _____ _____
Academic Appointment _____ _____
Board Certification _____ _____
At any time have you ever been named as a defendant in a prosecution
whether convicted, acquitted or dismissed of:
Any felony _____ _____
Any misdemeanor _____ _____
Have you ever at any time or are you currently:
Under indictment for any crime _____ _____
The subject of an investigation by any private, federal or
state health insurance program _____ _____
The subject of any adverse action reports from the
National Practitioner Databank _____ _____
Have you ever either voluntarily or involuntarily:
Withdrawn your application for medical staff membership at a facility _____ _____
Withdrawn your request for any clinical privileges at any facility _____ _____
Had your privileges restricted or been suspended for any reason _____ _____
Relinquished, or made any agreement to avoid adverse action,
preclude investigation _____ _____
Please answer the following:
1. Are you able to safely and competently exercise the clinical privileges requested and perform the duties and responsibilities of appointment, including, but not limited to, emergency service coverage and committee service, either with or without reasonable accommodation?
_____ YES _____ NO
If you require reasonable accommodation to perform the duties and responsibilities of appointment please list any special accommodations that are required:
________________________________________________________________________________
2. Are you currently using illegal substances or illegally using substances? _____ YES _____ NO
3. I agree that I do not have any communicable disease and further understand that if at any time I am considered to be infectious, I will notify the MCC Medical or Executive Director immediately.
_____I AGREE _____ I DISAGREE
4. I agree that I will not release any information regarding patient’s diagnosis, finance, etc. unless authorized to do so. I will strictly adhere to patient confidentiality and privacy standards.
_____ I AGREE _____ I DISAGREE
STATEMENT OF APPLICANT (PLEASE READ CAREFULLY BEFORE SIGNING THE APPLICATION)
All information submitted by me in this application is true to the best of my knowledge and belief. I authorize MCC and Excela Health officials to consult with administrators and members of medical staffs of other hospitals or institutions with which I have been associated and with others, including past and present malpractice carriers, who may have information concerning my professional competence, character and clinical qualifications.
I authorize Excela Health and MCC representatives to release and exchange information to each other in order to evaluate his or her professional qualifications for appointment, privileging, and credentialing at MCC and with the federal government in relation to the FTCA application for deeming and free malpractice insurance to volunteer at MCC. To the fullest extent permitted by law, I release from all liability, extend absolute immunity to, and agree not to sue Excela Health, MCC, members of their respective Medical Staffs and/or Boards, authorized representatives, and third parties who provide information for any matter relating to appointment, reappointment, credentialing, and privileging to volunteer at MCC. This immunity covers actions, recommendations, reports, statements, communications, and/or disclosures involving me that are made, taken or received by Excela Health, MCC, their authorized agents, or third parties in the course of credentialing, privileging, and peer review activities.
In making this application, I acknowledge that I am familiar with the principles and standards of the Joint Commission and that I will abide by the Principles of Medical Ethics of the American Medical Association and/or the Code of Ethics of the American Dental Association as they are currently amended, whichever is applicable.
I understand that I have the responsibility to keep the information in this application current and will inform the MCC director of any changes. I agree to read the applicable Bylaws, Policies, Rules and Regulations for MCC and agree to be bound by the terms thereof. I have not requested privileges for any procedures for which I am not trained and clinically competent. I believe I am qualified to perform all procedures for which I have requested privileges.
By signing this application, I hereby certify that all information contained in this application is true, correct and complete in all respects and agree to promptly notify the “recipient” immediately if there are any changes in the information provided. I attest that I have obtained the required medical education as required by the Commonwealth of Pennsylvania for medical licensure. My signature on this application attests that I will comply with the above listed behavioral values.
I certify that the information included in this application is true and accurate.
I certify that I am healthy and fit to perform the work requested of me at MCC and the privileges I requested.
__________________________________________________________ ____________________________
Applicant’s Signature Date
__________________________________________________________
Printed Name
Complete all items on the application and attached pages, include all requested forms, and mail/give to:
Westmoreland Hospital
Attn: Office of Medical Affairs
532 West Pittsburgh St.
Greensburg, PA 15601
Print Name _______________________________________
Date_______________________________________
Complete all items on the application and attached pages, include all requested forms, and mail/give to:
Westmoreland Hospital
Attn: Office of Medical Affairs
532 West Pittsburgh St.
Greensburg, PA 15601
Core Privileges Include:
• Evaluate, diagnose, and treat adult patients with illnesses, diseases, and functional disorders of the circulatory, respiratory, endocrine, metabolic, musculoskeletal, hematopoietic, gastroenteric, and genitourinary systems including disorders common to adults. Includes performance of history and physical exam. The core privileges in this specialty include the procedures (listed below) and such other procedures that are extensions of the same techniques and skills.
• Administration of local anesthesia
• Laceration Repair (non-tendon)
• I & D of Cutaneous/Subcutaneous Lesions
• Removal of Foreign Bodies (Cutaneous and Subcutaneous)
• Nail Avulsion
• Excision of Skin Lesions
• Punch Biopsy
• Joint Injection / Aspiration
• Practitioner performed microscopy
• Waived Testing to include hemocult, urine dipstick, urine HCG, hemoglobin, glucose, and rapid strep screen.
I AM A: PHYSICIAN ( PA-C ( CRNP (
|( I request all core primary care medicine privileges |
|I request Core with the following exceptions: |
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Reappointment Requirements:
To be eligible to renew core privileges in primary care medicine, the applicant must meet the following maintenance of privilege criteria:
Current demonstrated competence and an adequate volume of experience, where indicated, with acceptable results in the privileges requested for the past 2 years based on results of ongoing professional practice evaluation and outcomes. Evidence of current ability to perform privileges requested is required of all applicants for renewal of privileges.
I have requested only those privileges for which by education, training, current experience, and demonstrated performance I am qualified to perform and for which I wish to exercise at Majesty Care Clinic.
Any restriction on the clinical privileges granted to me is waived in an emergency situation.
Signed_______________________________________________ Date
Print Name ___________________________________________
RELEASE, IMMUNITY, AND
EXCHANGE OF CONFIDENTIAL INFORMATION
[Part of the Majesty Care Clinic Application Form.]
I hereby authorize Excela Health (“Hospital”) and Majesty Care Clinic (“Clinic”) to release to each other Confidential Peer Review Information regarding my professional qualifications. For purposes of this authorization, “Confidential Peer Review Information” includes any and all information and/or documentation regarding my clinical competence and/or professional conduct that may be obtained or produced as part of the credentialing, quality assessment, or peer review processes at Hospital or Clinic.
I understand that any Confidential Peer Review Information that is released shall be used solely for credentialing, quality assessment, and peer review purposes. I further understand that Hospital and Clinic will maintain any Confidential Peer Review Information that they receive in strict confidence, in accordance with the protections and privileges afforded peer review information under Pennsylvania and/or federal law.
I hereby extend absolute immunity to, release from any and all liability, and agree not to sue Hospital, Clinic, or their employees, agents, or representatives for (1) releasing Confidential Peer Review Information to one another for credentialing, quality assessment, and peer review purposes, and (2) any action that may result from the release of Confidential Peer Review Information.
Signature of Practitioner
Printed or Typed Name of Practitioner
Date
IT IS NOT NECESSARY TO RETURN THIS SHEET. IT IS FOR YOUR USE TO BE CERTAIN YOU
RETURN ALL REQUESTED ITEMS.
Complete all items on the application and attached pages, include all requested forms, and mail/give to:
Westmoreland Hospital
Attn: Office of Medical Affairs
532 West Pittsburgh St.
Greensburg, PA 15601
COMPLETED APPLICATION AND ALL ATTACHMENTS ARE NECESSARY TO BE ELIGIBLE TO APPLY FOR FTCA FREE MALPRACTICE INSURANCE AND TO BEGIN VOLUNTEER WORK AT MAJESTY CARE CLINIC. PLEASE CALL THE EXECUTIVE DIRECTOR AT THE CLINIC OR EMAIL HIM/HER AT majestycareclinic@ IF YOU HAVE ANY QUESTIONS CONCERNING ANY ITEM.
APPLICATION CHECK LIST
_____ Completed Volunteer Application
_____ Photocopy of your PA Professional License. The License must be active or a current volunteer license
_____ Copy of current (must be within 1 year) TB (PPD) report if available
_____ Copy of current CPR certification if available
_____ Copy of driver’s license or other government issued photo ID
_____ Current (within 2 years) Criminal Background Check if available
_____ Majesty Care Clinic Privilege Request Form
_____ Release, Immunity, and Exchange of Confidential Information Sheet
Independent Professionals: those who work independently because of their license, certificate, or registration (Includes doctors & nurse practitioners, and some social workers, psychologists), etc.
Independent Professionals require primary source verification of credentials (direct verification from the place where the information is kept. Ex: the state health dept for the license or the academic institution for the education - med school, residency, specialty training, and any other training from the facility they trained in) license, education, and other training.
Non-independent professionals: the only primary source verification is for the license, certificate, or registration and it must come from the state issuing agency. This may be done online by MCC or Excela as our CVO.
Secondary Source Verification: Additional information for both Independent and Non-independent professionals can be verified from the volunteers themselves including a copy of the license (however the professional’s copy cannot be used for primary source verification), picture id, cpr training certificate, tb test results, etc.
IT IS NOT NECESSARY TO RETURN THIS SHEET.
A copy of this paper will be returned to you after all documentation is received and verified prior to volunteering at MCC.
Majesty Care Clinic Privilege Request Recommendation
To be completed by Majesty Care Clinic Staff
A copy of the recommendation will be returned to the applicant.
Recommendation
I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and approve them as noted above.
c
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|( Recommend all core privileges |
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|Recommended with the following modification(s) and reason(s): |
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|Not Recommended |
Signed ___________________________________________________ Date_________________________
Printed
Name ___________________________________________________
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