Biographical sketch, kathy matzka, cpmsm, cpcs



Download 464.18 Kb.
Page2/15
Date conversion19.11.2016
Size464.18 Kb.
1   2   3   4   5   6   7   8   9   ...   15

Exercise: Applying Criteria for Medical Staff Appointment



Using the Sample Medical Staff Bylaws Language for Medical Staff Appointment and Sample application (following pages) determine whether the applicant should be sent an application based on bylaws requirements.




Sample Medical Staff Bylaws Language

Criteria for Medical Staff Appointment


Section 1. General Qualifications
Every practitioner who seeks or enjoys Medical Staff appointment must, at the time of application and initial appointment must demonstrate, to the satisfaction of the appropriate authorities of the Medical Staff and of the Board, the following qualifications:
A. Licensure: The following are required:

  • A currently valid M.D., D.O., DDS, DMD, DPM license issued by the State of Louisiana;

  • Current valid Federal DEA Certificate; and

  • Current Illinois Controlled Substance License

B. Professional Education and Training:


Graduate of an approved medical or dental school or school of osteopathy or podiatry, or certified by the Educational Council for Foreign Medical Graduates, or have a Fifth Pathway Certificate and have passed the foreign Medical Graduate Examination in the Medical Sciences; and, if a physician, satisfactory completion of at least three years in an approved postgraduate training program; if a dentist, satisfactory completion of at least two years in an approved postgraduate training program; if a podiatrist, satisfactory completion of at least two years in an approved post graduate training program. An "approved" postgraduate training program is one fully accredited throughout the time of the practitioner's training by the Accreditation Council for Graduate Medical Education, by the Commission on Dental Accreditation, or by the Council on Podiatric Medical Education.
C. Board certification by the appropriate specialty Board (American Board of Medical Specialties, American Osteopathic Association, American Dental Association, Council on Podiatric Medical Education, or one of their subspecialty boards); or proof of admissibility for examination for certification by the appropriate specialty Board, and thereafter certified within (5) years of completion of residency training.
D. Residence and office location sufficiently close to the hospital to fulfill medical staff responsibilities and to provide timely and continuous care for patients.
E. Disability:
To be free of or have under adequate control any significant physical or mental health impairment and to be free from abuse of any type of substance or chemical that affects cognitive, motor or communication ability in a manner that interferes with, or presents a reasonable probability of interfering with, the ability to perform privileges requested or carrying out the responsibilities of medical staff membership.

F. Verbal and Written Communication Skills:


Ability to read and understand the English language, to communicate in writing and verbally in the English language in an intelligible manner, and to prepare medical record entries and other required documentation in a legible manner.
G. Professional Liability Insurance:
Professional liability insurance of $1 million per occurrence and $5 million annual aggregate.
H. Alternate Coverage:

Each practitioner must assure timely, adequate professional care for his/her patients in the Hospital by being available or designating a qualified alternate practitioner with whom prior arrangements have been made and who has the requisite clinical privileges at this Hospital to care for the patient. The name of such alternate must be provided on application to the medical staff.


I. Hospital and Community Need, and Ability to Accommodate:
In acting on new applications for Medical Staff appointment and clinical privileges, and on applications for changes in clinical privileges, in Medical Staff appointment status, or in principal Department affiliation, the Board may also consider any policies, plans and objectives formulated by it concerning:
1. the Hospital's current and projected patient care, teaching and

research needs; and

2. the Hospital's ability to provide the physical, personnel and financial resources that will be required if the application is acted upon favorably.


SAMPLE APPLICATION FOR APPOINTMENT TO MEDICAL STAFF

LAST NAME FIRST NAME MIDDLE NAME DEGREE

Smith Josiah Thomas MD

Other Name Used/Maiden Name __________________________________________________

Specialty: General and Vascular Surgery




BOARD CERTIFICATION

List the certifying board, the specialty, the date of certification/recertification & expiration.

Name of Board



Am Board Surgery

Specialty



General Surgery

Certification/Recertification Date(s)



1/1/83, 6/30/03, 6/30/2013

Expiration Date



12/31/2020

Name of Board



Specialty


Certification/Recertification Date(s)


Expiration Date


 Not planning to take boards  Not eligible to take boards

 Board certification in process. Date scheduled or taken ___/___/___ Specialty___________



GENERAL INFORMATION

Citizenship (If foreign national – USA Status)



USA

Social Security Number



321-897-3876

Date of birth



12/13/49

Medicare UPIN



A2194


PRIMARY OFFICE ADDRESS:

Approximate distance from hospital: 30 miles

Street and Suite Number



1110 N. 9th Street

City


O’Fallon

State


IL

Zip


62269

Telephone Number ( 618) 223-8998

FAX ( 618) 223-8990

Exchange Number ( ) Pending


Name of Office Manager

Jennifer Johnston



SECONDARY OFFICE ADDRESS:

Approximate distance from hospital:

Street and Suite Number



City

State

Zip

Telephone Number ( )

FAX ( )

Name of Office Manager



HOME ADDRESS:

Approximate distance from hospital: 40 miles

Street Address



43 Green Acres

City


Godfrey

State


IL

Zip


62035

Home Phone ( 618) 224-8726


Cell Phone Number (618 ) 222-7262



LICENSES AND REGISTRATION

State


IL

License Number



036-4598874

Date Granted



3/30/99

Expiration Date



6/30/15

State


LA

License Number



MD 413679

Date Granted



7/5/75

Expiration Date



12/31/99

State


IL Cont Sub

License Number



031-036-4598874

Date Granted



3/30/99

Expiration Date



6/30/15

Federal DEA Number




AS 1234567

Date Granted



7/30/75

Expiration Date



7/30/15



EDUCATION/TRAINING

MEDICAL SCHOOL


Name


U of Illinois


Address, City, State, Zip



Chicago, IL


Dates of Attendance Degree Granted/Date

From: 5/71 To: 5/75 MD



If Foreign Medical Graduate:

ECFMG # Date Issued:

RESIDENCY #1


Name


Earl Long Medical Center


Address, City, State, Zip



Shreveport, LA


Dates of Attendance Specialty

From: 7/75 To: 6/77 General Surgery



Name of Program Director


RESIDENCY #2


Name


LA State University



Address, City, State, Zip



Shreveport, LA


Dates of attendance Specialty

From: 7/77 To: 6/81 General Surgery



Name of Program Director





FELLOWSHIP


Name




Address, City, State, Zip





Dates of attendance Specialty

From: To:



Name of Program Director







ALTERNATE(S) - List the name of the Medical Staff appointee(s) who will serve as your alternates and/or proctors.

ALTERNATES:



Don’t have one at this time. Am discussing with several surgeons on your staff.




WORK HISTORY/HOSPITAL AFFILIATIONS, PAST AND PRESENT

List work history, starting with the present. Include office practice, teaching appointments, employers, current and past hospital affiliations. If additional space is needed, provide details on separate sheet and attach.

Name of Organization, Hospital, or Office Practice



St. Jude Memorial Hospital

Address, City, State, Zip



4501 St. Jude Place, Shreveport, LA

From: 7/81 To: 12/98



Position



Surgeon

Name of Organization, Hospital, or Office Practice



St. Stephen Catholic Hospital


Address, City, State, Zip



12 Main Street, Scoville, Il, 63421

From: 4/99 To: Present



Position



Surgeon

Name of Organization, Hospital, or Office Practice



Address, City, State, Zip


From: To:



Position


Name of Organization, Hospital, or Office Practice


Address, City, State, Zip



From: To:


Position

Name of Organization, Hospital, or Office Practice

Address, City, State, Zip


From: To:



Position









PERSONAL REFERENCES

List three peer references - NOT RELATED TO YOU OR A PROSPECTIVE PARTNER - who have personal knowledge of your current clinical ability, ethical character, and ability to work cooperatively with others. These references should have acquired their knowledge through recent observation of your professional performance and, at least one must have had organizational responsibility for supervision of your performance. (e.g. department chair, service chief, training program director).


Name


Adam West, MD

Address


11 Brown

Relationship



Colleague

City, State, Zip



St. Louis, MO 63108

Name


Tina Graham, M.D.

Address


University Hospital Emergency Department

Relationship



Colleague

City, State, Zip



St. Louis, MO, 63106

Name

Address

Relationship


City, State, Zip





PROFESSIONAL LIABILITY INSURANCE INFORMATION

NAME OF CURRENT CARRIER:



Lloyds of London

ADDRESS:


Lloyd's America Inc.
6340 Sugarloaf Parkway
Suite 200
Duluth
GA 30097

POLICY LIMITS



_500 K_________ per occurrence _1 mil annual aggregate

POLICY NUMBER:



MR 4437

DATE UNDERWRITTEN:



6/1/13

DATE OF EXPIRATION:



12/31/15

NAME(s), ADDRESS(s), AND POLICY NUMBERS FOR ADDITIONAL PROFESSIONAL LIABILITY INSURANCE CARRIERS YOU HAVE HAD OVER THE PAST FIVE YEARS:





PROFESSIONAL BACKGROUND
Please answer the following questions regarding your professional background. If the answer

to any question is "yes", please provide the nature and specific details on a separate sheet and attach.


YES NO

1. Have you ever voluntarily or involuntarily surrendered, or had any pending or

completed action involving the denial, revocation, suspension, reduction, limitation,

probation, reprimand, or non-renewal of,

a. a license or certificate to practice medicine or any profession in any state  

or country

b. Drug Enforcement Agency or other controlled substance license or registration  

c. membership or fellowship in any local, state, or national professional organization  

d. specialty or subspecialty board certification or eligibility  

e. faculty membership at any medical or other professional school  

f. staff membership or clinical privileges at any hospital, clinic, or healthcare institution  
3. Has any hospital, health plan, or government sponsored program ever restricted,  

suspended, invoked probation, or rejected or terminated your contract?

4. Have you ever been named as a defendant in a case alleging medical negligence,  

or has a suit for any alleged malpractice ever been brought against you?

5. Do you have any physical or mental health condition, treated or untreated,  

which in any way impairs your ability in terms of skill, attitude, or judgment

to practice to the fullest extent of your license and qualifications or in any way

poses a risk of harm to your patients?

6. Have you ever been convicted of a felony, or currently have felony charges  

pending?


APPLICANT'S CONSENT AND RELEASE
I hereby apply for appointment to the Medical Staff of State Hospital. In making application for appointment to the Medical Staff of State Hospital, I certify that I have received, read, and agree to be bound by the Medical Staff Bylaws, Rules and Regulations and related manuals, and the current hospital policies that apply to my activities as a Medical Staff appointee and that are consistent with the Medical Staff Bylaws, Rules and Regulations and related manuals. Moreover, I specifically pledge that I will maintain an ethical practice, provide for continuous care of all my patients, refrain from feesplitting or other inducements relating to patient referral, and refrain from providing "ghost" surgical or medical services.

I certify that there has not been any unsuccessful or currently pending challenges to licensure or registration, no loss of medical or dental organization membership, nor loss of medical staff membership or privileges at another hospital, except as noted herein. I understand that my competence and general functioning and performance with regard to my patients and my duties and obligations as a Medical Staff appointee of State Hospital, will be reviewed from time to time by my peers working within the structure of the Medical Staff in accordance with the Bylaws thereof. I hereby give my permission for, and in fact request, such review pursuant to my appointment and reappointment to the Medical Staff of State Hospital, that I will not bring legal action to prevent such review or to recover damages from those participating in such review.


By applying for Medical Staff appointment, I accept the following conditions below during the processing and consideration of my application and for the duration of my medical staff appointment regardless of whether or not I am granted Medical Staff appointment and clinical privileges:

(a) I extend absolute immunity to and release from any and all liability, State Hospital, its authorized representatives, and any third parties, as defined in subsection (c) below, for any acts, communications, reports, statements, documents, recommendations or disclosures involving me, performed, made, requested or received by any third party, including otherwise privileged or confidential information.

The foregoing shall be privileged to the fullest extent permitted by law; such privilege shall extend to the hospital and its authorized representatives, and to any third parties.

(b) I specifically authorize the hospital and its authorized representatives to consult with any third party who may have information, including otherwise privileged information, bearing on my professional qualifications, credentials, clinical competence, character, mental or emotional stability, physical condition, ethics, behavior or any other matter bearing on my satisfaction of the criteria for Medical Staff appointment as well as to inspect any and all communications, reports, statements, documents, recommendations, or disclosures of said third parties relating to such questions. I also specifically authorize said third parties to release such information, including any and all peer review material from any and all hospitals wherein I have held appointments, to the hospital and its authorized representatives upon request.

(c) The term "hospital and its authorized representatives" means State Hospital and any of the following individuals who have any responsibility for acting upon my application for Medical Staff appointment: the members of the hospital's Board and their appointed representatives, the Chief Executive Officer or his designees, other hospital employees, consultants to the hospital, the hospital's attorney(s) and his/her partners, associates or designees, and all appointees to the Medical Staff. The term "third parties" means all individuals, including appointees to the medical staffs of other hospitals or physicians or health practitioners, nurses or other government agencies, organizations, associations, insurance companies, managed care organizations, credentials verification organizations, partnerships and corporations, whether hospitals, health care facilities or not, from whom information has been requested by the hospital or its authorized representatives or who have requested such information from the hospital and its authorized representatives.
I also agree to provide any additional information as may be requested by the hospital or its authorized representatives. Failure to produce this information will prevent my application from being evaluated and acted upon.

A copy of this consent and release is a binding as the original. In submitting this application for the purpose of securing appointment to the Medical Staff of State Hospital, I hereby voluntarily state that all of the information above is complete and truthful. I also voluntarily state that I have made no effort to evade telling the complete truth regarding my professional career. I understand that any incomplete or false statement will lead to automatic withdrawal of this application for appointment. Should I be appointed to the Medical Staff of State Hospital and it is subsequently found that any statement above is false I understand that my Medical Staff appointment and privileges will be automatically terminated.

SIGNATURE______________________________________DATE___________________________
PRINTED OR TYPED NAME_______Josiah Smith, M.D.___________________________________
Review the application on the previous pages and list any “red flags”.

1   2   3   4   5   6   7   8   9   ...   15


The database is protected by copyright ©dentisty.org 2016
send message

    Main page