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Medical Staff and Allied Health Staff
Code of Excellence and Code of Conduct
Acknowledgement Form
This is to certify that I have received, read and understand the Code of Excellence and Code of Conduct.
The Code of Excellence/Code of Conduct is available to me at www.andersonhospital.org – under the Patients and Visitors tab – Legal and Regulatory Information, and on the Intranet - Home tab.
I acknowledge that I am fully aware that compliance with the Code of Excellence and Code of Conduct is a condition of my continued medical staff/allied health staff membership with Anderson Healthcare.
I further pledge and acknowledge the following:
1. That it is my duty to know and understand the ethical standards, legal standards and company policies applicable to performing my duties.
2. I pledge to act in compliance with the Code of Excellence and Code of Conduct and any compliance policies applicable to my responsibilities.
3. I pledge to be in full compliance with all applicable laws, federal health care program requirements and with Anderson policies and procedures.
4. I will report any conduct that I believe constitutes a violation of the Code of Excellence or Code of Conduct as outlined in the Codes.
5. I will seek advice from the Compliance Officer concerning appropriate actions that I may need to take in order to comply with the Code of Excellence or the Code of Conduct.
6. I understand that failure to comply with the Code of Excellence or Code of Conduct may subject me to disciplinary action.
__________________________________________________________________ Signature
__________________________________________________________________
Printed Name
__________________________________________________________________ Date
6800 State Route 162 Maryville, IL 62062
Phone: 618-391-6141 Fax: 618-288-2164
Provider Contact Information Please provide your contact numbers below, in order of preference, for the floors to contact you.
NAME:
CONTACT NUMBER
IN ORDER OF PREFERENCE
TYPE OF NUMBER
SPECIAL INSTRUCTIONS
1.
CELL HOME
PAGER OFFICE
EXCHANGE
2.
CELL HOME
PAGER OFFICE
EXCHANGE
3.
CELL HOME
PAGER OFFICE
EXCHANGE
4.
CELL HOME
PAGER OFFICE
EXCHANGE
5.
CELL HOME
PAGER OFFICE
EXCHANGE
Contact Number for E-prescribing clarification
CELL HOME
PAGER OFFICE
EXCHANGE
PRIMARY OFFICE ADDRESS: (PLEASE NOTE: THIS IS THE ADDRESS MEDICAL RECORD REPORTS WILL BE MAILED TO, IF APPLICABLE) OFFICE#: FAX #: EMAIL ADDRESS:
Provider Signature: ___________________________________ Date: __________________
Page 1 of 1
Supplemental Information
Name: 1. Home Address:
2. Phone Number: Home Cell
3. Marital Status (optional)
4. Name of Significant Other (optional) 5. Emergency Contact (if different from above)
6. Has your professional liability insurance carrier and/or the amount of professional liability insurance carrier changed? Yes No If yes, explain
7. Has your medical staff membership, staff category, scope of clinical privileges, or employment been
voluntarily or involuntarily changed or terminated at any hospital or other institution since your last application?
Yes No If yes, explain
8. Name(s) of physician(s) who have privileges at Anderson Hospital, with the same specialty as yours, who
will provide coverage. REQUIRED PER THE MEDICAL STAFF BYLAWS - 1.3(b)
8. Peer Evaluations are required by the Joint Commission. Please provide name and address of peer, within
your same specialty and preferably on staff at Anderson Hospital, whom we can contact to complete your Peer Evaluation, if necessary.
Anderson Hospital Medical Staff Status Description
Page 1 of 2
ACTIVE MEDICAL STAFF STATUS: Shall be those physicians, either resident or maintaining offices within the Hospital’s service area or a reasonable
distance therefrom, who have been selected to admit and attend patients in the Hospital. Must attend Medical Staff meetings (unless excused by the Medical Executive Committee or having attained the age of
sixty (60) years of age). Will serve upon not fewer than one of the Medical Staff’s standing committees. May vote on all Medical Staff business, hold Medical Staff offices and serve on Medical Staff Committees. Required to participate on the rotating list for emergency coverage. (Not required for age sixty (60) and older) After the first year, Active Staff members must admit or perform procedures on not fewer than twenty-four
(24) patients each reappointment cycle and/or attend not fewer than 24 patients admitted by other physicians.
Members of the Active Medical Staff, who fail to meet the requirements for membership on the Active Medical Staff, will be assigned to the Associate Medical Staff.
ACTIVE STAFF WITH MEMBERSHIP ONLY MEDICAL STAFF STATUS: Shall be those physicians, either resident or maintaining offices within the Hospital’s service area or a reasonable
distance therefrom, who utilize hospitalists for admissions and treatment of inpatients and actively use Hospital services, but wish to be active in the business of the Medical Staff.
Will attend not fewer than one Medical Staff standing committee. May vote on all Medical Staff business, hold Medical Staff offices, and serve on Medical Staff Committees. Required to participate on the rotating list for emergency coverage. (Not required for age sixty (60) and older) Members will refer not fewer than twenty-four (24) patients to hospital services each reappointment cycle. Members of the Active Staff with Membership Only who fail to attend required meetings, will be assigned to the
Membership Only staff. ASSOCIATE MEDICAL STAFF STATUS: Shall consist of physicians who do not wish to actively participate in the work of the Medical Staff. In certain instances,
Associate Medical Staff may be asked to participate in peer review. May attend General Staff and meetings of the clinical departments and committees. May not vote on any Medical Staff business, hold office, or chair any Medical Staff committee. Required to participate on the rotating list for emergency coverage. (Not required for age sixty (60) and older) After the first year of appointment, they shall admit or perform procedures on not fewer than twenty-four (24)
patients each reappointment cycle. Members of the Associate Medical Staff, who fail to meet the requirements for membership on the Associate Medical Staff,
will be assigned to the Courtesy Medical Staff. COURTESY MEDICAL STAFF STATUS: Shall consist of those members of the medical profession who are eligible as herein provided for Medical Staff
membership, who wish to admit private patients to the Hospital, but who do not wish to become members of the Active Medical Staff.
Members are not required to attend Medical Staff meetings. May not vote on any Medical Staff business, hold Medical Staff office or serve on Medical Staff committees. May not admit or perform procedures on more than twenty-four (24) patients each reappointment cycle. Physicians admitting or performing procedures on more than 24 patients shall be advanced to another Medical Staff
category. CONSULTING MEDICAL STAFF STATUS: Shall consist of physicians of recognized unique professional ability or specialty who are active in the Hospital or who
have signified a willingness to accept such appointment. Duties shall be to render their services upon request of any member of the Medical Staff.
Members are not required to attend meetings. May not vote on any Medical Staff business, hold Medical Staff office or serve on Medical Staff committees. May not admit or perform procedures.
Anderson Hospital Medical Staff Status Description
Page 2 of 2
AFFILIATE MEDICAL STAFF STATUS: Shall consist of physicians who are on staff at Anderson Hospital whose primary purpose is to provide coverage for
Active and Associate Medical Staff members. Duties shall be to provide coverage for his/her associate(s) as needed. Members are not required to attend meetings. Members may not vote on any Medical Staff business, hold Medical Staff office or serve on Medical Staff committees. No required volume. MEMBERSHIP ONLY MEDICAL STAFF STATUS: Shall be those physicians, either resident or maintaining offices within the Hospital’s service area or a reasonable
distance therefrom, who utilize hospitalists for admissions and treatment of inpatients and utilize the hospital services and wish to be affiliated with the Medical Staff but not active in the business of the Medical Staff.
Members are not required to attend meetings. May not vote on any Medical Staff business, hold Medical Staff office or serve on Medical Staff committees. NO HOSPITAL PRIVILEGES.
HONORARY MEDICAL STAFF STATUS: Shall consist of physicians who are not active in the Hospital and who are honored by emeritus positions. These may be: 1) Physicians who have retired from active Hospital service;
or 2) Physicians of outstanding reputation not necessarily residing in the community. Shall not vote or hold office and may not have assigned duties. Shall not admit patients. NO HOSPITAL PRIVILEGES.
MEDICAL STAFF MEMBER CONSENT AND RELEASE
I extend absolute immunity to, and release from any and all liability, Anderson Hospital, its Medical Staff, its Authorized Representatives, and any Third Parties, all as defined below, for any acts, communications, statements, recommendations or disclosures performed in good faith and without malice, including otherwise privileged or confidential information, relating to or in connection with this Reapplication or the consideration of the privileges sought herein. I specifically authorize Anderson Hospital and its Authorized Representatives to consult with any Third Party who may have information, including otherwise privileged or confidential information, bearing on my professional qualifications, credentials, clinical competence, character, mental or emotional stability, physical condition, ethics, behavior or other matter bearing on my satisfaction of the criteria for initial and continued appointment to the Medical Staff, and to inspect or obtain copies of any and all communications, reports, records, statements or documents from Third Parties relating to such matters. I also specifically authorize said Third Parties to disclose and release any such information to Anderson Hospital and its Authorized Representatives upon request. Any and all information received from Third Parties shall be confidential and shall not be released to the Applicant. I further authorize and consent to the release of information and records concerning me by Anderson Hospital to other hospitals, medical associations, governmental agencies or other bodies concerned with professional competency, medical malpractice or practitioner licensing, and I hereby release from liability Anderson Hospital and its Authorized Representatives for so doing. The Term “ Authorize Representatives” means Anderson Hospital and any of the following individuals who have any responsibility of obtaining or evaluating my credentials, or acting upon my Reapplication or conduct in Anderson Hospital: The members of Anderson Hospital’s Board of Trustees and their appointed representatives; the members and officers of the Medical Staff of Anderson Hospital; the President of Anderson Hospital or his designees; other hospital employees; consultants to the hospital and the hospital’s attorneys. The term “ Third Parties” means all individuals and entities, including but not limited to physicians, health practitioners, hospitals, government agencies, associations, partnerships and corporations, from whom information concerning me or this Reapplication has been or is requested by Anderson Hospital or its Authorized Representatives, or who have requested such information form Anderson Hospital or its Authorized Representatives.
_____________________ ____________________________________________ Date Signature
____________________________________________ Printed Name
REAPPLICANT'S ATTESTATION I hereby apply for medical staff reappointment and clinical privileges as requested in this reapplication. I am willing to make myself available for interviews in regard to this reapplication. As a reapplicant, I have the burden of producing adequate information for proper evaluation of this Reapplication. I agree to provide Anderson Hospital with updated current information regarding all questions on this reapplication as such information becomes available and such additional information as may be requested by Anderson Hospital or its Authorized Representatives. I represent that the information given in or attached to this reapplication is accurate and fairly represents that current level of my training, experience, capability and competence to practice. I REALIZE AND AGREE THAT ANY MISREPRESENTATION, SIGNIFICANT MISSTATEMENT OR OMISSION IN THIS REAPPLICATION SHALL CONSTITUTE GROUNDS FOR DENIAL OF REAPPOINTMENT OR TERMINATION OF ANY CLINICAL PRIVILEGES GRANTED. I understand that this reapplication will be considered in accordance with the By-laws, Rules and Regulations of the Medical Staff of Anderson Hospital, and agree to be bound by those By-laws, Rules and Regulations. I understand that I have the burden of establishing my eligibility and competence. By applying for reappointment and clinical privileges, I accept that I have the responsibility to keep this reapplication current by informing the hospital, through the Chief Executive Officer or his designee. I understand I am obligated to notify the hospital, through the Chief Executive Officer or his designee, immediately for professional license revocation, federal Drug Enforcement Agency license revocation, or any lapse in professional liability coverage. I further understand I must notify the hospital, as noted above, within in 5 days of any corrections, updates, and modifications for Medicare or Medicaid sanctions, revocation of any hospital privileges, or conviction of a felony, and within 45 days for any other change in information from the date the health care professional knew of the change. All updates should be made on the Healthcare Professional Data Gathering form, which is mandated by the state of Illinois. I specifically agree to abide by all By-laws, policies, directives, Rules and Regulations as are in force during the time I am reappointed to the Medical Staff or exercise clinical privileges at Anderson Hospital. I agree to abide by all of the ethical principles established by the national association of my profession. I agree not to receive from or pay to any other physician, either directly or indirectly, any part of any fee paid for professional services. I agree to provide continuous care and supervision for all of my patients at Anderson Hospital.
_____________________ ____________________________________________ Date Signature
____________________________________________ Printed Name
HEALTH STATEMENT
To be completed by the reapplicant: Do you have a physical or mental condition which could affect your ability to exercise the clinical privileges requested or would require an accommodation in order for you to exercise the privileges safely and competently?
Yes No
Reapplicant Name (Please print) Reapplicant's Signature Date Regardless of how the above question is answered, the reapplication will be processed in the usual manner. If you have answered this question affirmatively and are found to be professionally qualified for medical staff appointment and the clinical privileges requested, you will be given an opportunity to meet with an appropriate committee to determine what accommodations are necessary or feasible to allow you to practice safely. To be completed by your Primary Care Physician (PCP): I do hereby certify that physician listed above is in good physical and mental health to carry out the duties necessary in the performance of his/her profession. Any limitations or restrictions placed on this Healthcare professional are as follows: Comments: Attending Physician (please print) Date
Attending Physician Signature
CONTINUING MEDICAL EDUCATION (CME’s)
List the continuing education sessions and hours which you have completed in the last two years. Attach either a copy of certificates of attendance for each program attended or list as follows:
Name of Program/Topic
Sponsored by
Dates of Attendance Hours
Total Hours
If requested, I agree to submit proof of attendance and program content. Provider Signature Date
LOW VOLUME VERIFICATION Date: _____________
To whom it may concern,
I am in the reappointment process and have had low activity at Anderson Hospital. I am requesting verification of my clinical activity to fulfill my reappointment requirements. I authorize you to release this information to Anderson Hospital. Please return this form ASAP. The form may be mailed to Anderson Hospital, Medical Staff Office, 6800 State Route 162, Maryville IL 62062 or faxed to 618-288-2164. Thank you. ____________________________________ ______________________________________________ Requesting Provider’s Signature Requesting Provider’s Printed Name
Please note: This information is to be completed by your PRIMARY FACILITY, NOT BY PROVIDER. Current Staff Status: __________________________ Date of Initial Appointment: _____________________ 1. Please provide the following utilization at your facility for the past two years:
Number of Admissions: ____________________________ Number of Procedures: ____________________________ *Provide a list of each procedure & the number performed Number of Consultations: ____________________________
2. Please provide a copy of this provider’s current delineation form from your facility. 3. 4. This provider’s clinical performance for the privileges he/she has been granted has been:
Acceptable _______ Above Average _______ Unacceptable _______ Average _______ Below Average _______
_______________________________________________ _________________________ Signature of Dept. Chairperson or Designee Date Printed Name & Title: ____________________________________________________________ Hospital/Organization: ____________________________________________________________ Address/City/State/Zip: ____________________________________________________________
AUTHORIZATION FORM ̶̶ www.backgroundcheckadvantage.com 8/23/2016
Anderson Hospital Brittany Mersinger, RHIT
618‐391‐6140
First Name Middle Name Last Name
Alias/Maiden Name(s) Will Employee's Salary Exceed $75,000?
No Yes
Social Security Number Date of Birth Race Gender
Male Female
Mailing Address (NO P.O. Boxes) City State Zip
As part of the employment volunteer student credentialing process, I consent to the release of my criminal background records and motor vehicle driving records or any search listed below by any and all states or agencies holding such records. I also agree to an investigation and the obtaining of a consumer report solely for employment volunteer student credentialing purposes. By signing this consent, I acknowledge I have received in writing a Disclosure Regarding Procurement of a Consumer Report. I understand that the Company named above may use this consent on multiple occasions to request such consumer reports. This consent will remain effective until I have affirmatively revoked it.
Signature of Applicant Date: ________ /________ /________
BACKGROUND SEARCHES
OIG (Medicare/Medicaid Fraud & Abuse) GSA (Federal Procurement Fraud) **FCSR
SSN Plus (Address & Alias Name are included) Address Verification Alias Name Search
Government Watch List (includes DOC Entity List & Denied Persons List, DOT Specially Designated Nationals & Blocked Persons List, DOS Proliferation List & more)
Wants & Warrants (Nationwide ‐ extraditable only) OFAC (Specially Designated Nationals and Blocked Persons List)
Child Abuse/Neglect – IL** IA** IN** KS** MO* NE** TN Adult Abuse/Neglect – KS
*MO Mental Health Employee Disqualification Registry MO EDL (Employee Disqualification List)
FEDERAL COURTS ‐ Criminal State 1: _______ 2: _______ SEX OFFENDER Nationwide or State 1: _________
DRIVING RECORD State _________ DL# __________________________________________________
PROFESSIONAL LICENSE National or State _________ Type: _________________________________________________ License #: _______________________________________________
EDUCATION School Name (include campus): ________________________________________________________________________
City/State: _____________________ /______ Major: _________________________________ Graduation Date: ____ /___________
Degree Type: ____________ (BSN, B.A., etc.) Name While Attending: ____________________________________________________ If additional Verifications are needed, refer to application during data entry or document on another Background Check Request Form.
CHARACTER REFERENCE PERSONAL PROFESSIONAL: Name ________________________________ Phone: _____ /______‐_______ EMPLOYMENT Company: ________________________________________________ City/State: _____________________ /_____
Phone: _____ /______‐_______ Manager: ________________________________ Start Date: ___ /______ End Date: ___ /______
Title: _________________________________________________ Starting Wage:$_______________ Ending Wage:$_____________Duties: ________________________________________________________________________________________________________
Reason for Leaving: ______________________________________________________________________________________________ If additional Verifications are needed, refer to application during data entry or document on another Background Check Request Form.
LIST CITY/COUNTY CRIMINAL SEARCHES NEEDEDStates with county by county access only: CA, LA, MA, WV and WY
County 1:_________________State: ______ County 2:_________________State: ______ County 3:_________________State: ______
STATEWIDE CRIMINAL ‐ A Statewide/State Repository houses records from all jurisdictions throughout the State
AL* AK* AZ AR* CO CT* DE DC* FL GA* HI ID** IN IA* KS KY ME MD MI MN MO MS* MT NE NV* NH** NJ NM* NY* NC* ND OH* OK OR* PA RI* SC SD TN TX UT* VA* VT* WA WI Note: Nevada & Ohio are Felony Only
Illinois Healthcare‐compliance with IL Healthcare Worker Background Check Act (IL Police Full‐State Repository Criminal) International Criminal _______________________________________________
MO‐includes MO Sex Offender results at no additional cost (MO State Highway Patrol Full‐State Repository Criminal search)
*Required Form(s) & **Required Special Form(s) must be ATTACHED when ordering or faxed to 573‐893‐7669
Anderson Conflict of Interest Agreement
I agree to avoid all actual and perceived conflicts of interest and shall abide by the Conflict of Interest –Medical Staff Allied Health Staff and Workforce Policy. I understand that a conflict of interest arises when there is a conflict between one’s personal stake in a matter and his/her fiduciary responsibility to Anderson caused by a financial interest, position, activity or other relationship with a third party. I understand it is not possible to list all types of conflicts of interests, but agree that the following general principles are areas to consider as potential conflicts and agree to avoid them:
►Products and services are to be bought and sold based solely on their value and merit. If I am involved in purchasing goods or pricing services I may not give, receive, offer or solicit any personal gifts or favors or any payment in the nature of a bribe or kickback that influences or might appear to influence purchase and pricing decisions. ►Any outside activity, such as a second job or a significant interest in another business, shall not involve any personal interest that could affect my independent judgment with my duties or discredit or embarrass Anderson. ►I or my immediate family may not have any personal interest in any sale or purchase of property by Anderson. ►I may not convey Anderson property or proprietary or confidential information or provide unpaid services to a member of the public or to an employee or agent unless approved in writing by a member of senior management/Chairman of the Board of Trustees, as appropriate. ►I shall disclose all possible conflicts of interest when those interests may affect or be perceived as affecting a decision on a proposed Anderson transaction or arrangement.
I may not enter into any agreement or arrangement that calls for a commission, rebate, consultant or service fee, bribe, kickback or should suspect from the surrounding circumstances or after a good faith inquiry, that the intent or probable results is to reward improperly, either directly or indirectly including:
►Any employee or official or other representative of any government or governmental agency or entity (including the military). ►Any officer, director, trustee, employee, shareholder or other representative of an institution with which Anderson has an existing or prospective business relationship.
►Any officer, official, member or other representative of a union. I will not give inducement to such individuals to take action favorable to Anderson or myself. The concept of an improper reward includes the giving of anything of value. Examples such as free or special price services or trips at Anderson’s expense, without a proper business purpose, may constitute an improper payment just as readily as a cash payment. No action that would otherwise be
suspect shall be permissible merely because it appears to be customary in a particular location or particular area of business activity. I understand that the practices of write‐offs, discounting and forgiveness of debt shall be subject to interpretation as gifts, inducements or even bribes. I understand that requests for special billing or payment procedures that suggest possible violations of law such as evasion of income tax, currency exchange controls or price, profit controls are contrary to policy and no such billing, or payment procedures shall be used. Such practices can also result in false, artificial or misleading entries in the books or records of Anderson and are prohibited. I understand that I am subject to termination of my position if it is determined that I have violated this agreement. I understand that I should disclose any situation that may potentially result in a conflict of interest so as to permit an impartial and objective determination. Please answer the following questions: 1. Do you have another job?
□ Yes: Include name of employer and job title: ______________________________________
□ No
2. Do you work or consult for a healthcare vendor who sells medical products or services?
□ Yes: Include Name of healthcare vendor and job duties:______________________________
□ No 3. Do you, your spouse, mother/father; grandparents; brothers/sisters; adult children have full or partial financial ownership in a healthcare/healthcare related business?
□ Yes: Include name of the business and list family member(s) who have full or partial financial
ownership: __________________________________________________________________
□ No
4. □ After reading this form, do you have any other information to disclose which you believe might
create or possibly give the perception of a conflict of interest?
□ Yes: please describe: __________________________________________________________
□ No Comments: ____________________________________________________________________________________ ___________________________________________ ___________________________ Signature Date ___________________________________________ ___________________________ Printed Name Position/Title
FORWARD TO A PEER WITHIN
SAME SPECIALTY
PEER RECOMMENDATION AT REAPPOINTMENT I have reviewed the requested privileges of this reapplication for whose specialty is . I find that the applicant is: Qualified for the privileges requested. Qualified for the privileges requested with the following exceptions or
conditions:
Reasons for Exceptions or Conditions: Not Qualified for the privileges requested. Printed Name of Peer Reviewer Signature of Peer Reviewer Date
11/15/16
TO: The Medical Staff of Anderson Hospital, Maryville, Illinois requires each Medical Staff appointee and applicant to provide evidence of medical professional liability insurance coverage in the exact amounts of coverage per occurrence and per annual aggregate. Please send a Certificate of Medical Liability Insurance or other documentation to Anderson Hospital verifying the class of my insurance, the exact limits of the coverage I have with your company, and claims history. I also authorize Anderson Hospital to verify specific privileges covered under my policy as well as any limitations of my coverage. If available, we have attached a copy of the policy for your convenience. Please identify Anderson Hospital as the certificate holder on my policy.
________________________________ _______________________ Signature Date ________________________________ Printed Name
Office Address City State Zip
Home Address City State Zip
Anderson Hospital Illinois Route 162
Maryville, Illinois 62062 Medical Staff Office
618-391-6141 Phone 618-288-2164 Fax
NOTICE TO PHYSICIANS
Medicare, Medicaid, and Champus payment to hospitals is based in part on each patient’s principal and secondary diagnoses and the major procedure 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 this essential information required for payment of Federal funds, may be subject to fine, imprisonment, or civil penalty under applicable Federal laws.
------------------------------------------------------------------------------------------------- I acknowledge that I have received and read the above statement, concerning Medicare, Medicaid and Champus payment to hospitals and the penalties as stated.
___________________________________ ______________________ Physician’s Signature Date
___________________________________ Printed Name