nemours physician application packet

Nemours Physician Application Packet

Dear Dr. Doctor: Welcome to Nemours. Enclosed is an application to the Medical Staff of the Nemours Healthcare Facility at which you will see patients. If you do not already have a license in the state(s) in which you are applying to practice for Nemours, we recommend that you do this immediately (see information below). Our credentials verification process takes an average of 60 days after our receipt of your completed application. In order to start your employment as scheduled, complete and return your application as soon as possible, but no later than 30 days from receipt. If you are awaiting licenses for which you have already applied, you may submit your application prior to your receipt of those licenses provided you forward copies of the licenses, CDS (if applicable), and DEA (with your anticipated practice address) as soon as you receive them. A delay in returning your application will result in a delay in your start date with Nemours Please complete the enclosed application in full – do not attach your CV in lieu of completing the application in full, but include a copy of your CV as well. FILL IN EACH SECTION OF THE APPLICATION IF AN ITEM IS NOT APPLICABLE PLEASE WRITE "NOT APPLICABLE.” DO NOT LEAVE BLANKS. INCLUDE ALL MOONLIGHTING OR LOCUM TENENS POSITIONS YOU HAVE HELD. PROVIDE COMPLETE MAILING ADDRESSES, FAX NUMBERS OR EMAIL ADDRESSES AND THE MONTH/YEAR OF ATTENDANCE OR MEMBERSHIP. INCOMPLETE APPLICATIONS MAY RESULT IN A DELAY IN YOUR START DATE. Return the completed application to the attention of the Corporate Credentialing Department, along with copies of the following documents:

1. Current State License(s) where you will be practicing for Nemours if (display copy – not wallet size) - Delaware State license application is available online at

http://www.professionallicensing.state.de.us. - Florida State license application is available online at http://www.doh.state.fl.us/mqa/medical/ap_me1501.pdf

2. Copy of specialty Board Certification. 3. ECFMG Certificate for those completing Medical School outside the

United States or Canada. 4. If you are not a U.S. citizen, include a copy of your Visa. 5. Certificate of Insurance (minimum coverage required – $3million each

claim; $3 million aggregate) OR State specified requirements for the state in which you will be working for Nemours?

6. Copy of Medical School diploma

7. Copies of Training certificates from Internship, Residency and Fellowship programs

8. If you served in the military, enclose a copy of your discharge papers (DD214)

9. If you have experienced a name change, enclose a copy of the legal document effecting this change.

10. Enclose documentation of your attendance at continuing education programs during the past three years.

11. Copy of your FEDERAL DEA with a Delaware Office Address or address of state where you will be working for Nemours if other than Delaware. Applications are available online at http://www.deadiversion.usdoj.gov/

12. For practice in Delaware or New Jersey only - Copy of your State CDS (Delaware or New Jersey State Controlled Dangerous Substance Registration) Application is available online at Delaware - http://www.professionallicensing.state.de.us. Under Pharmacy – Forms to print out, complete and mail in with your check for $40.00. New Jersey – https://newjersey.mylicense.com/ Florida and Pennsylvania – Do not have a CDS requirement

13. Sign and Date the Physician Acknowledgement form 14. Copy of a government issued photo ID (passport or driver’s license). 15. Copy of your current Curriculum vitae (C.V.) All dates must be in

month and year format (not year only). 16. If provided, your signed and checked-off clinical privilege list including

any additional documentation listed under criteria for initial appointment, i.e. a Letter from the Chairman of your training program, or if greater than 5 years, a letter from the Chief or Chairman of the Hospital department where you currently practice such privileges attesting to your competence to perform requested procedures. Some locations will not have clinical privilege forms, for example if you are using as your primary admitting facility a hospital other than a Nemours Hospital.

17. Copy of your Social Security Card. 18. Complete Conflict of Interest Declaration – see enclosed letter for

details. Upon receipt of your completed application, we will verify all elements of the application via a specific written questionnaire sent directly to each individual or institution listed so please be sure to include accurate and complete mailing addresses and contact names. If we are unable to verify any part of the information provided for credentialing, we will contact you to assist in obtaining the necessary verification or information. The burden of proof and provision of this information for your credentialing is your responsibility. If 60 days after we have notified you of our inability to obtain any response and that verification is still missing (120 to 180 days into the process) your application will be considered to have been voluntarily

withdrawn and will not be processed as outlined in the Credentials Committee Policy. When all the information is verified, your application will be evaluated by the Division Chief and Department Chairman prior to presentation to the Credentials Committee. You may be required to appear for a personal interview with the Credentials Committee. ***************************************************************** Please review the enclosed attachment which outlines Medical Staff categories at the various Nemours locations to assist you in making your decision about the category to which you wish to apply. Return the completed application and required documents to:

Corporate Credentialing Department Nemours PO Box 269 Wilmington, DE 19899

Questions regarding the application form or process should be referred to the Corporate Credentialing Department at (302) 651-5631, (904) 697-4020, or (302) 651-6076. PLEASE NOTE: ANY MISREPRESENTATION, MISSTATEMENT OR OMISSION FROM THIS APPLICATION, WHETHER INTENTIONAL OR NOT, IS CAUSE FOR AUTOMATIC AND IMMEDIATE REJECTION OF THIS APPLICATION.

NEMOURS PHYSICIAN APPLICATION FOR INITIAL CREDENTIALING

GENERAL INSTRUCTIONS:

This application must be completed in full and all questions answered in full If not applicable please indicate with “N/A” Print or type all responses in black ink If there is insufficient space on this form, attach additional sheets Attach copies of your CV, CME activity for the last 3 years Attach privilege form & documentation to support the level of privileges/procedures you have

requested (if applicable) Sign & date and return the completed application to

Corporate Credentialing Department

Nemours 1600 Rockland Road, P.O. Box 269

Wilmington, DE 19899 Phone: 302-651-5631/651-6076; Fax: 302-651-6077

PERSONAL INFORMATION: NAME IN FULL:_____________________________________________________DEGREES:______________________ Please list any other names you have used, including maiden name, married name, non-anglicized, etc.:____________________________________________________________________________________________ CURRENT OFFICE ADDRESS:________________________________________________________________________ _______________________________________________________________________________________________ City State Zip OFFICE TELEPHONE:_________________ OFFICE FAX #:_________________EMAIL :_________________________ ANTICIPATED OFFICE (If you are in the processing of joining a new practice please list that address below) ADDRESS:______________________________________________________________________________________ OFFICE TELEPHONE:________________ OFFICE FAX #:__________________EMAIL:_________________________ HOME ADDRESS:_________________________________________________________________________________ HOME TELEPHONE:__________________ E-MAIL ADDRESS:_____________________________________________ DATE OF BIRTH:___________________GENDER:_______ SOCIAL SECURITY :_______________________________

(Required for processing a query to the National Practitioner Data Bank) PLACE OF BIRTH:____________________________CITIZENSHIP:____________________________________________ (City, State & Country) If not a citizen of the United States please indicate the status of your

visa at the present time:__________________________________

PRIMARY LANGUAGE:____________________ SECONDARY LANGUAGE:________________________

Rev. 11/2010 Application for Appointment - Page 2

Person to contact in case of emergency: ____________________________________________________________________Relationship:____________________ Address:_________________________________________________________________Telephone:__________________ LIST THE NAME, ADDRESS, TELEPHONE, FAX NUMBER AND EMAIL ADDRESS OF THE CONTACT PERSON YOU WOULD LIKE US TO USE WHEN CORRESPONDING WITH YOU ABOUT THIS APPLICATION: ______________________________________________________________________________ EDUCATION: List all non-medical post-secondary schools attended as a regular student, using a separate sheet if necessary. UNDERGRADUATE Month/Day/Year College/University Attendance From Date Address Line 1 Attendance To Date Address Line 2 Date of Graduation City/State/Zip Code Degree/Major College/University Attendance From Date Address Line 1 Attendance To Date Address Line 2 Date of Graduation City/State/Zip Code Degree/Major College/University Attendance From Date Address Line 1 Attendance To Date Address Line 2 Date of Graduation City/State/Zip Code Degree/Major MEDICAL/PROFESSIONAL EDUCATION: (Attach a copy of your diploma) Month/Day/Year Medical/Professional School

Date of Graduation

Address Line 1 Attendance From Date Address Line 2 Attendance to Date City/State/Zip Code Degree Medical/Professional School

Date of Graduation

Address Line 1 Attendance From Date Address Line 2 Attendance to Date City/State/Zip Code Degree Did you complete your Medical/Professional School Program in the normal length of time?

Yes No - If no, please provide a detailed explanation below


If a graduate of a medical school outside the United States or Canada, provide address of school and copy of ECFMG certificate. ECFMG #:_____________________ National Board of Medical Examiners:_____________________ Date/Location FLEX:_________________________ Date/location POST-GRADUATE MEDICAL TRAINING: List all post-graduate medical training for the following categories, regardless of whether or not completed. (Attach a copy of your training certificates for each program attended) INTERNSHIP/PGY 1: Hospital Program Type Address Line 1 Start Date Address Line 2 Completion

Date

City/State/Zip Code Director’s Name Email Address Phone/Fax

Number

Hospital ProgramType Address Line 1 Start Date Address Line 2 Completion

Date


Number

RESIDENCIES/PGY 2+: Hospital Program Type Address Line 1 Start Date Address Line 2 Completion

Date


Number

Hospital Program Type Address Line 1 Start Date Address Line 2 Completion

Date


Number



Date


Number

FELLOWSHIP: Hospital Program Type Address Line 1 Start Date Address Line 2 Completion

Date


Number


Date


Number


Date


Number

TRAINING PROGRAM ACTIONS YES** NO During your internship(s), residency(s), or fellowship(s), were you ever suspended disciplined, placed under probation, formally reprimanded, or asked to resign in order to avoid disciplinary action?

Have you ever voluntarily or involuntarily left a training program prior to its completion? Have you ever, while under investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship or other clinical education program?

**If Yes, provide an explanation below OTHER: ____________________________________________________________________________________________ ____________________________________________________________________________________________


MILITARY SERVICE: Have you ever served in the Military? Yes** No

**If yes, Attach evidence of discharge from Military Service (Form DD214) If yes, please complete information below Name/Address Last Assignment

Date Entered Military Month/ Day/Year

Date of Discharge Month/Day/Year

LICENSURE/REGISTRATION: List ALL licenses and registrations ever held or applied for including training licenses and Attach copy(ies) of your current Medical License(s) for all states in which you plan to practice

State/Territory

Type of License

Number

Status (Active/Prior)

Issue Date

Expiration Date

If not currently licensed in the state(s) where you will be practicing, have you applied Yes No to the State Board of licensure for your specialty? List state(s) name(s):________________________________________________________________________ When do you anticipate receiving that license?____________________________________________________ Federal DEA Registration (attach a copy)

Number:______________________ Expiration Date:_____________ State:_________ Number:______________________ Expiration Date:_____________ State:_________ Number:______________________ Expiration Date:_____________ State:_________

A separate DEA is required for each state in which you actively practice for Nemours the practice address on the DEA certificate determines the State.

State Issued Controlled Substance Registration (CSR or CDS):

Required if you intend to Practice for Nemours in the States of Delaware, New Jersey or Maryland

Number:______________________ Expiration Date:_____________ State:_________ Number:______________________ Expiration Date:_____________ State:_________ Number:______________________ Expiration Date:_____________ State:_________

NPI (National Provider Identification) Number _________________________


Attach a copy of your official notification of this number BOARD CERTIFICATION (Attach evidence of Board Certification, Re-certification/Maintenance of Certification or Application to take the Board Examination) BOARD CERTIFICATION YES NO Are you Board Certified? (If yes, continue to question #2. If no, please answer a and b below)

a. If you are not Board Certified, do you plan to become certified in your medical specialty? b. If yes, provide estimated date of certifying examination & date qualification expires: Have you been examined by any specialty Board but failed to pass? If yes, provide details below

List all Board Certifications Ever Held and enclose a copy with your application:

Specialty Board/Certification Date of Certification

Recertification Due Date

MOC Expiration

date

CHRONOLOGY OF PROFESSIONAL PRACTICE: List all past and professional activities by category indicated in chronological order, most recent first. Use additional pages if more space is necessary. Provide documentation of your activities during any periods of time not otherwise listed below HOSPITAL & OTHER INSTITUTIONAL AFFILIATIONS: (LIST ALL PRESENT, PRIOR & PENDING APPLICATIONS IN CHRONOLOGIC ORDER- INCLUDING YOUR ANTICIPATED PRIMARY ADMITTING FACILITY). INCLUDE ALL MOONLIGHTING OR LOCUM TENENS POSITIONS YOU HAVE HELD. PROVIDE COMPLETE MAILING ADDRESSES, FAX NUMBERS OR EMAIL ADDRESSES AND THE MONTH/YEAR OF ATTENDANCE OR MEMBERSHIP PRIMARY ADMITTING HOSPITAL Anticipated Primary Admitting Facility

Affiliation From Date

Address Line 1 Affiliation To Date Address Line 2 Phone Number City/State/Zip Code Fax Number Department/Service Email Staff Category Dept. Chair’s Name OTHER HOSPITAL AFFILIATIONS Facility Name Affiliation From Date Address Line 1 Affiliation To Date Address Line 2 Phone Number City/State/Zip Code Fax Number Department/Service Email Staff Category Dept. Chair’s Name


Facility Name Affiliation From Date Address Line 1 Affiliation To Date Address Line 2 Phone Number City/State/Zip Code Fax Number Department/Service Email Staff Category Dept. Chair’s Name Facility Name Affiliation From Date Address Line 1 Affiliation To Date Address Line 2 Phone Number City/State/Zip Code Fax Number Department/Service Email Staff Category Dept. Chair’s Name Facility Name Affiliation From Date Address Line 1 Affiliation To Date Address Line 2 Phone Number City/State/Zip Code Fax Number Department/Service Email Staff Category Dept. Chair’s Name Facility Name Affiliation From Date Address Line 1 Affiliation To Date Address Line 2 Phone Number City/State/Zip Code Fax Number Department/Service Email Staff Category Dept. Chair’s Name

If you require additional space, please list on a separate page and attach ACADEMIC/TEACHING APPOINTMENTS Facility Name Appoint. From Date Address Line 1 Appointment To Date Address Line 2 Phone Number City/State/Zip Code Fax Number Department/Service Email Position/Title Dept. Chair’s Name Facility Name Appoint. From Date Address Line 1 Appointment To

Date

Address Line 2 Phone Number City/State/Zip Code Fax Number Department/Service Email Position/Title Dept. Chair’s Name


Facility Name Appoint. From Date Address Line 1 Appointment To

Date

Address Line 2 Phone Number City/State/Zip Code Fax Number Department/Service Email Position/Title Dept. Chair’s Name PROFESSIONAL PRACTICE AND WORK HISTORY (List all periods of time since receiving your medical degree not otherwise accounted for on this application). INCLUDE ALL MOONLIGHTING OR LOCUM TENENS POSITIONS YOU HAVE HELD. PROVIDE COMPLETE MAILING ADDRESSES, FAX NUMBERS OR EMAIL ADDRESSES AND THE MONTH/YEAR OF EMPLOYMENT. CURRENT EMPLOYER: Employer’s Name Start Date Address Line 1 End Date Address Line 2 Phone Number City/State/Zip Code Fax Number Department/Service Email Supervisor’s Name PRIOR EMPLOYERS: Employer’s Name Start Date Address Line 1 End Date Address Line 2 Phone Number City/State/Zip Code Fax Number Department/Service Email Supervisor’s Name Employer’s Name Start Date Address Line 1 End Date Address Line 2 Phone Number City/State/Zip Code Fax Number Department/Service Email Supervisor’s Name Employer’s Name Start Date Address Line 1 End Date Address Line 2 Phone Number City/State/Zip Code Fax Number Department/Service Email Supervisor’s Name Employer’s Name Start Date Address Line 1 End Date Address Line 2 Phone Number City/State/Zip Code Fax Number Department/Service Email Supervisor’s Name Date (month/day/year) began practice __________________________________________


TIME GAPS/BREAKS BETWEEN EMPLOYMENT, BREAKS BETWEEN TRAINING PROGRAMS, ETC. List below all time periods (two weeks or more) not otherwise included in this application, such as leave of absences, relocating, etc. Date From

Date To List Your Activities During this Period of Time

MALPRACTICE POLICY INFORMATION (Enclose a copy of your current certificate of malpractice insurance): List chronologically beginning with current all malpractice coverage insurance information for the last seven (7) years, including training programs and locum tenens positions. If there are any gaps in your coverage, provide a detailed explanation. Insurance Carrier Name

Coverage Start Date

Address Line 1 Coverage End Date Address Line 2 Phone Number City/State/Zip Code Fax Number Policy Number Email Contact’s Name Insurance Carrier Name

Coverage Start Date


Coverage Start Date


Coverage Start Date

Address Line 1 Coverage End Date Address Line 2 Phone Number City/State/Zip Code Fax Number Policy Number Email Contact’s Name


Insurance Carrier Name

Coverage Start Date


Coverage Start Date


Coverage Start Date

Address Line 1 Coverage End Date Address Line 2 Phone Number City/State/Zip Code Fax Number Policy Number Email Contact’s Name PROFESSIONAL LIABILITY INSURANCE COVERAGE HISTORY

YES** NO

Has your professional liability insurance coverage ever been terminated or has an individual surcharge been asses by action of an insurance company?

Have you ever been denied professional liability insurance coverage?

Has any insurance company every restricted, limited or delineated the procedures you may perform or the scope of your practice as a condition of providing insurance coverage?

**If Yes to any or all the above three questions, provide a detailed explanation below MALPRACTICE CLAIMS INFORMATION

YES** NO

Have any professional liability claims or malpractice claims EVER been filed against you or settled by you or on your behalf, whether in a court or before an administrative body? **If Yes, list the exact number of claims filed ________________and provide detailed descriptions below

LIST ALL MALPRACTICE CLAIMS IN WHICH YOU HAVE EVER BEEN NAMED INCLUDING DROPPED CASES WITHDRAWN CASES, SETTLED CASES OR PENDING CASES


For each claim noted above, the Credentials Committee requires a very comprehensive description of the medical facts (must include, but not be limited to, the type of treatment and/or surgery rendered, result of treatment and current status of patient’s injury; your involvement, i.e., consultant, primary physician, assistant in surgery, etc.) Date of Incident:__________________ Description:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Current Status: Dropped Settled Name withdrawn Pending

Total amount settled $_____________Amount paid on your behalf $______________ Date of Incident:__________________ Description:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Current Status: Dropped Settled Name withdrawn Pending

Total amount settled $_____________Amount paid on your behalf $______________ Date of Incident:__________________ Description:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Current Status: Dropped Settled Name withdrawn Pending

Total amount settled $_____________Amount paid on your behalf $______________ Date of Incident:__________________ Description:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ If additional space is necessary, please provide a full explanation of details on a separate sheet. ABILITY TO PERFORM: Yes No


Are you able to perform all of the mental and physical functions related to the clinical privileges you have requested, with or without reasonable accommodations?

Do you or have you engaged in unlawful or inappropriate use of drugs, including the use of prescription drugs not under the supervision of another licensed health care professional? If Yes, please identify and describe any steps you have taken and any program(s) in which you are or have been enrolled to assure your abstinence prospectively and that drug use will not interfere with your practice of medicine, patient care responsibilities, or your adherence to applicable standards of professional performance or conduct?

Has the consumption of alcohol ever interfered with your practice of medicine, patient care responsibilities, or adherence to applicable standards of professional performance or conduct? If Yes, please identify and describe any steps you have taken and any program(s) in which you are or have been enrolled to assure that alcohol consumption will not interfere with your practice of medicine, patient care responsibilities or your adherence to applicable standards of professional performance or conduct.

REFERENCES: Name three (3) medical or health care professionals in your field of practice (i.e. physicians for physicians, dentists for dentists) who have personal knowledge of your current (you have worked with them in the past 2 to 3 years) clinical abilities, ethical character, health status and ability to work cooperatively with others and who will provide specific written comments on these matters upon request from the Credentials Committee of the Medical Staff. The named individuals must have acquired the requisite knowledge through recent observation of your professional practice over a reasonable period of time and at least one must have had organizational responsibility for your performance. Preferably the individuals should not be related to you by family or recently initiated or impending professional partnership/financial association.

At least one reference must be your current Supervisor, Department Chair or Medical Director

(Do not use your residency or fellowship training program Director as a reference – they will be contacted separately)

Complete Name and Mailing Address, e-mail & phone/fax number: Reference Name Phone Number Facility where applicant worked with reference

Professional relationship with peer (colleague/supervisor)

Address Line 1 Phone Address Line 2 Fax City/State/Zip Code Email Reference Name Phone Number Facility where applicant worked with reference


Address Line 1 Phone Address Line 2 Fax City/State/Zip Code Email


Reference Name Phone Number Facility where applicant worked with reference


Address Line 1 Phone Address Line 2 Fax City/State/Zip Code Email PROFESSIONAL STATUS: Disciplinary And/Or Voluntary Actions: Either voluntarily or involuntarily, have any of the following ever been or are currently being denied, revoked, suspended, relinquished, reduced, limited, placed on probation, withdrawn, not renewed or investigated? Licensure/Registration: YES** NO Has your application or license to practice medicine, Drug Enforcement Administration (DEA) registration, or an applicable narcotics registration in any jurisdiction, ever voluntarily or involuntarily been denied, limited, suspended, revoked, relinquished, withdrawn, restricted, surrendered or not renewed, or have you ever been subject to a consent order, probation or any conditions or limitations by any licensing board?

Has any state licensing board or DEA fined you, reprimanded you, or found you to be in violation of any law or regulation?

Have any disciplinary actions or investigations been initiated and/or are any such actions or investigations now pending against you by any state licensing board or the DEA?

Medicare, Medicaid or other Governmental Program Participation YES** NO Have you ever voluntarily or involuntarily been suspended from participation, fined, disciplined, limited, reprimanded, sanctioned, restricted or excluded from participation for any reason by Medicare, Medicaid, or any public program? Is any such action pending?

Hospital Privileges and Other Affiliations: YES** NO Have you ever voluntarily or involuntarily withdrawn, relinquished, or been denied clinical privileges, membership, contractual participation, or employment by any healthcare organization (e.g., hospital medical staff, medical group, health plan, health maintenance organization, private payer, medical society, professional association, medical school faculty position, or any other health delivery entity or system)?

Have your clinical privileges, membership, contractual participation, or employment at any healthcare organization (as defined in the above question) ever been suspended, restricted, revoked, surrendered, not renewed, or subject to probation (for reasons other than non-completion of medical records) or other disciplinary conditions, or have proceedings towards any of those ends been instituted or recommended? Is any such action pending?

Have you ever voluntarily or involuntarily surrendered clinical privileges, accepted a limitation or restriction of your privileges, terminated contractual participation or employment, or resigned from any healthcare organization (e.g., hospital medical staff, medical group, health plan, health maintenance organization, private payer, medical society, professional association, medical school faculty position, or any other health delivery entity or system ) while under any investigation for possible incompetence, improper professional conduct, disruptive conduct, or failure to adhere to professional standards or standards of care, or in return for such an investigation not being conducted or completed. Or not reapplied for privileges?

Has your membership or fellowship in any local, county, state, regional, national, or international professional organization ever voluntarily or involuntarily been revoked, suspended, denied, limited, withdrawn, or not renewed. Is any such action pending?


Hospital Privileges and Other Affiliations: YES** NO Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (Including HMO’s, PPO’s, or provider organizations such as IPA’s, PHO’s)

Education, Training and Board Certification: YES** NO Have you ever voluntarily or involuntarily been denied certification and /or re-certification by a specialty board? Has your eligibility status changed with respect to certification and/or re-certification by a specialty board and/or have any of your board certifications or eligibility ever been revoked?

Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation?

Criminal/Civil History: YES** NO Have you ever been convicted of any crime, other than minor traffic offenses, but including driving under the influence of drugs or alcohol, or is any criminal proceeding currently pending against you?

Have you ever been convicted of, pled guilty to, or pled nolo contendere (no contest) to any felony in the last ten years or been found liable or responsible for or named as a defendant in any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional?

Have you ever been convicted of, pled guilty to, or pled nolo contendere (no contest) to any felony or been found liable or responsible for or been named as a defendant in any civil offense that alleged fraud, an act of violence, child abuse or sexual offense or sexual misconduct?

Have you ever been court-martialed for actions related to your duties as a medical professional?

Malpractice Claims History YES** NO Have you ever been denied professional liability insurance or had professional liability insurance revoked or threatened with revocation, or had your practice in any way limited as a condition of any insurance coverage?

Other Sanctions, Investigation or General Information YES** NO Are you currently or have you ever been the subject of an investigation by any hospital, licensing authority, DEA or CDS authorizing entities, education or training program, Medicaid or Medicaid program, or any other private, federal or state health program?

Have you ever received sanctions from or been the subject of investigation within the last ten years by any regulatory agencies (e.g. CLIA, OSHA, FDA, etc.?)

Is there any other information relevant to your professional status that is not requested or addressed above, but that a responsible professional would disclose as a part of the application process? If yes, please provide explanation on a separate page.

Have you ever been convicted of, pled guilty to, pled nolo contendere (no contest) to sanctioned, reprimanded, restricted, disciplined or resigned in exchange for no investigation or adverse action for sexual harassment or other illegal misconduct?

Have you ever been investigated, sanctioned, reprimanded or cautioned within the last ten years by a military hospital, facility, or agency, or voluntarily terminated or resigned while under investigation within the last ten years by a hospital or healthcare facility or any military agency?

Has a patient, parent, legal guardian or other individual ever filed a complaint against you with any State, local or Federal agency or professional society?


If your answer to any of the following questions is “yes”, please provide full details on a separate sheet.

CURRICULUM VITAE/RESUME Attach a current copy of your CV (curriculum vitae) which should reflect your present employment: CONTINUING MEDICAL EDUCATION CREDITS Attach a list of all continuing education activities you have attended in the past three years, including name of program, date of program, and number of credit hours received. (If you have completed your training program within the last six months this is not required).


CLINICAL INTERESTS (for publication in directory): ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ CLINICAL PRIVILEGES: I AM REQUESTING CLINICAL PRIVILEGES IN THE SPECIALITY OF __________________________________

Complete and attach the clinical privileges delineation form. Privileges should be requested based upon current competence.

If you are requesting any of the supplemental privileges noted on the attached list, submit with your application evidence of training and experience as required under privilege

criteria listed on the attached privilege form. PRACTICE ASSOCIATES: Provide the names of the practitioner(s) with whom you are associated in practice and the nature of the association and the name of your practice: ____________________________________________________________________________________________ ____________________________________________________________________________________________ COVERAGE ARRANGEMENTS: I have made arrangements with the following practitioner(s) _________________________________________ ___________________________________________________________________________________________ To provider coverage for my patients in my absence and I have confirmed that this practitioner/group practice members has/have current privileges with Nemours Hospitals for Children to provide coverage for me.

Have you answered all questions and included all required attachments Missing information will delay the credentialing process

and may result in a delay in your start date

ANY MISREPRESENTATION, MISSTATEMENT OR OMISSION FROM THIS APPLICATION, WHETHER INTENTIONAL OR NOT,

MAY BE CAUSE FOR AUTOMATIC AND IMMEDIATE REJECTION OF THIS APPLICATION


NEMOURS CHILDREN’S CLINICS, FLORIDA

LOCATION (Select application location(s): √ Locations Jacksonville Orlando Pensacola STAFF CATEGORY REQUESTED (Select one): Please refer to the Medical Staff Bylaws for a complete definition of each category. √ Category Active CLINICAL AFFILIATION REQUESTED: Practice Limited to (list specialty):______________________________________________________________________ √ Primary Department Appointment: Anesthesiology/Critical Care Medical Imaging/Radiology Pathology Pediatrics Surgery

CONDITIONS OF APPLICATION: By applying for appointment to the Medical Staff of the Nemours Children’s Clinic, I hereby: signify my willingness to appear for interviews regarding my application; authorize the Clinic, its Medical Staff and their representatives to consult with prior associates and others who

may have information bearing on my professional competence, character, health status, ethical qualifications, ability to work cooperatively with others, and other qualifications for membership and the clinical privileges I request and consent to the release of such information by prior associates.

consent to the review and inspection by the clinic, its medical staff and their representatives of all documents that may be material to an evaluation of my qualifications and competence;

release from liability the Nemours Children’s Clinic, all representatives of the Clinic and its staff for the acts performed and statements made in good faith and without malice in connection with evaluating my application and my credentials and qualifications;

release from liability all hospitals and other organizations and their representatives who provide information regarding my credentials and qualifications in good faith and without malice upon request of the Nemours Children’s Clinic staff

agree to notify the Credentials Committee in writing, within five (5) days of receiving any written or oral notice of any adverse action, including without limitation, any filed and served malpractice suit or arbitration action; any adverse action by the Florida Board of Medicine, or any other medical license board, taken or pending, including but not limited to, any accusation filed, temporary restraining order or interim suspension order sought or obtained, public letter of reprimand, public reproval, and any formal restriction, probation, suspension or revocation of licensure; any adverse action taken by any healthcare organization, which has resulted in a report to the Florida Board of Medicine, or a report with the National Practitioner Data Bank; any revocation of DEA license; a conviction of, or the institution of proceedings related to, any crime (other than minor traffic offenses); any action against any certification under the Medicare or Medicaid programs; or any cancellation, non-renewal or material reduction in medical liability insurance policy coverage or the initiation against me of any proceedings relating to any of the foregoing;

acknowledge that I have received, or been given access to, and read the Rules and Regulations and any other manuals and policies relevant to the application process and generally to clinical practice, and agree to be bound by the terms thereof in all matters related to Medical Staff membership and clinical privileges and to the consideration of my application for appointment and reappointment to the Medical staff and for clinical privileges;

agree to abide by the Rules and Regulations, Policies and Procedures, and Policies and Procedures of Nemours. acknowledge that the provisions of said Rules and Regulations relating to confidentiality and release from

liability are express conditions of my application for, and acceptance of, medical staff membership and the continuation of such membership and to my exercise of clinical privileges;

pledge to maintain an ethical practice, to provide for continuous care for my patients, and to refrain from delegating the responsibility for any aspect of the care of my patients to any practitioner not qualified to undertake that responsibility;

acknowledge that I, as an applicant for medical staff membership and privileges, have the responsibility for producing adequate information for a proper evaluation of my professional, ethical and other qualifications for membership and clinical privileges and for resolving any doubts about such qualifications; and

I represent that the information provided in or attached to this application is accurate and complete. I understand that a condition of this application is that any misrepresentation, misstatement or omission from this application, whether intentional or not, is cause for automatic and immediate rejection of this application by the Nemours Children’s Clinic and may result in denial of my application or termination of my membership with the Clinic staff. I further understand that any misrepresentation, misstatement or omission from this application, if discovered after membership to the Clinic staff has been awarded to me, may lead to immediate suspension or termination of those privileges. I agree to use my best efforts to inform the Nemours Children’s Clinic in writing within 15 days if there is any change in the information provided or the answers to questions on the application as a result of developments subsequent to my signing this application. Photographic reproductions of this form and my signature are as fully effective as the original. Signature: ________________________________________ Date:____________________ Printed Name: The Nemours Children’s Clinic will treat this application and any information secured in connection thereof in strict confidence and will employ all reasonable safeguards to protect the applicant’s privacy. Form 57007 (07/10)

nemours physician application packet

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