W:\KM\MCHS Med Staff Svcs\Initial Application\Initial Application Packets\Initial Application Documents\CHECKLIST - AHP 4.12.19.docx Revised 3/2017

ALLIED HEALTH INITIAL APPLICATION CHECKLIST

Incomplete applications will not be processed. Forms must be completely filled out, signed and dated

Date of signature must be within 30 days of receipt of the application by the CVO

□ 1. Call the CVO (614-546-3540) or email CVO@mchs.com to request the clinical privilege form

□ 2. Non-refundable Application Fee; payable to Mount Carmel Health System (Grove City/East = One medical staff) □ One medical staff $500 □ Two medical staffs $800 □ Three medical staffs $1000

□ 3. Completed CAQH application must be on file with the CAQH and attestation current within the past 120 days (A handwritten CAQH or a CAQH Data Summary is not acceptable as an application)

□ 4. Application Addendum o Program Director or Department Chair identified as a professional reference

□ 5. Release of Information / Statement of Applicant

□ 6. Confidentiality and Network Access Agreement

□ 7. Disclosure / Conflict of Interest Statement

□ 8. Application for System Access

□ 9. New Privilege Applicant Letter

□ 10. Professional Liability Insurance face sheet; must be rated A- or better by A.M. Best (must list effective and expiration dates, applicant's name, coverage minimums of $1M/$3M) o Past 10 years must be identified on CAQH or a separate document

□ 11. DEA Certificate (if applicable)

□ 12. ACLS, BLS, NRP, etc.; if applicable for privileges requested NOTE: ACLS and BLS must be American Heart Association courses

□ 13. Electronic Fetal Monitoring (EFM) NCC certification (required for CNM)

□ 14. Standard Care Arrangement - CNP, CNS, CNM

□ 15. Affidavit - CRNA and CAA Only

□ 16. Supervision Agreement with the State Medical Board of Ohio - Physician Assistant Only

□ 17. Photo ID (Government issued) - must be legible (faxed copies are not legible)

□ 18. Curriculum Vitae/Resume; including work history; gaps of 28 days or more must be explained in writing

□ 19. Additional documentation may be required based on your specialty and/or clinical privileges

PLEASE KEEP A COPY OF ALL DOCUMENTS SUBMITTED FOR YOUR RECORDS RETURN ALL DOCUMENTS TO:

Mount Carmel Health System ▪ Credentialing Verification Office 6150 East Broad Street ▪ Columbus, OH 43213

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APPLICATION ADDENDUM

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GENERAL INFORMATION Applicant Name: ______________________________________________________________________________ Last First MI Degree

Current Home Address: ________________________________________________________________________ Street City State Zip Country Name of group/practice you are joining: ____________________________________________________________ Partners or associates: _________________________________________________________________________ CAQH Provider ID#:____________________ Date of Birth: ________________ SS#:_______________________ Cell Phone #:____________________________ Preferred Email: _______________________________________ Citizenship: __________________________________________________________________________________ Visa type: __________________ Effective date: __________________ Expiration date: _____________________ Military Service: Yes _____ No _____ Dates: ___________________________________________________ If discharged, please provide a copy of your DD214. Credentialing Contact Name: _______________________________________ Phone:_______________________ (if different than applicant)

Fax: _______________________________ Email: __________________________________________________

CATEGORY REQUESTED Check (√) the medical staff and category in which you wish to apply

Active

May Admit

Patients

> 50 pts / 2 years

Courtesy

May Admit

Patients

<50 pts / 2 years

Coverage

Back Up coverage for a physician w/

privileges.

May only admit under the name of

physician being covered

Consulting

May not admit patients

Clinical

Privileges and Consults only

Community

Based

No clinical privileges

House

Physician (contracted)

May not admit

patients

Clinical Privileges only

Allied Health

(Mid-Level Provider)

No admitting privileges

Locum Tenens

Telemedicine

Gove City/East

St. Ann’s

New Albany

If you are interested in becoming a participating provider with Mount Carmel Health Partners (managed care organization) please contact Justin Wolf at 614-546-3736, or by email at Justin.Wolf@mchs.com. The membership application documents will be sent under separate cover.

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Primary Hospital Designation If applying to more than one Medical Staff

Please designate the facility below which will be your primary hospital for fulfilling staff obligations of department meetings, committee appointments, and other administrative duties that may be assigned according to the Bylaws of the Medical Staff. This is the facility where you plan to have the most clinical activity. _____ Mount Carmel Gove City/East* _____ Mount Carmel St. Ann’s _____ Mount Carmel New Albany *If applying to Mount Carmel Grove City/East please designate between the two hospitals, the facility which will be your primary hospital for fulfilling staff obligations of department meetings: ______ Mount Carmel Grove City _____ Mount Carmel East _____ DUAL (active practice at both locations)

Alternate Coverage (Physicians Only) Designation of Alternate Coverage: I hereby name and authorize the following individual as my Alternate Practitioner to assure adequate / equivalent professional care for my patients in my absence. This individual must be a MEDICAL STAFF APPOINTEE WITH COMPARABLE PRIVILEGES at the Hospital(s) to which you are applying. MCGC/MCE:_________________________________________________________________________________ MCSA: _____________________________________________________________________________________ MCNA: _____________________________________________________________________________________

References References must be from practitioners in your professional discipline who have personal knowledge of your ability to practice. References must have worked with you at least three (3) months within the past three (3) years. References cannot be related to you, and only one reference may be a partner or affiliate. If not already listed on the CAQH, one (1) reference must be one of the following:

• Program Director – if you completed training within the past 5 years. • Department Chair – if you completed training more than 5 years ago. Must be from a hospital where you

actively practice or currently have privileges. 1) Program Director / Dept. Chair Reference: Name: ___________________________________________________________________________________

Address: _________________________________________________________________________________

_________________________________________ Phone: _________________________________

Email: ___________________________________________ Fax: ___________________________________

Relationship to applicant: __________________________________________________________________

2) Name: ___________________________________________________________________________________

Address: _________________________________________________________________________________

_________________________________________ Phone: _________________________________

Email: ___________________________________________ Fax: ___________________________________

Relationship to applicant: __________________________________________________________________

3) Name: ___________________________________________________________________________________

Address: _________________________________________________________________________________

_________________________________________ Phone: _________________________________

Email: ___________________________________________ Fax: ___________________________________

Relationship to applicant: ____________________________________________________________________

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IF YOU HAVE ALLIED HEALTH / MID-LEVEL PROVIDERS WHO WORK WITH YOU

Please note that your employed Allied Health / Mid-Level Providers must also apply/reapply and be processed separately through the Credentialing Verification Office. Please call 614-546-3540 or email CVO@mchs.com for application information.

PPD TESTING AND HEALTH VACCINE ATTESTATION Effective June 1, 2017, all Mount Carmel Health System care sites transitioned from the annual TB screening process to a TB skin test (PPD). Every Medical Staff member, must complete the below section, attesting that during the previous 12 months, he or she has undergone the recommended PPD. Based upon the results of the PPD, if any further evaluation or testing is warranted, the practitioner will also attest that he or she has followed those additional recommendations. For those practitioners that would like to be able to use N95 masks when interacting with patients who have active TB, Mount Carmel Employee Health can provide fit testing upon request. In addition, Mount Carmel Employee Health can also administer PPD skin testing at no charge. Contact them at the following numbers:

East: (614) 234-6036 St. Ann's: (380) 898-5589

PPD Date: Name of Facility:

Results: Positive Negative If new positive, date chest x-ray was done Results: Positive Negative

Have you received an Influenza Vaccine? Date of Last Vaccination:

Yes No If 'No' provide reason:

HEALTH ATTESTATION

Please check the appropriate response

_____ I certify that I am in good health and have no physical or mental limitations that would inhibit or prevent me from performing all appropriate procedures and services pursuant to the privileges I have requested in

this application.

_____ *I have a chronic illness, physical disability, and/or mental limitation to my health (which may include alcohol or drug use), but I believe this does not significantly impair my ability to render quality patient care.

*A full statement of explanation must be attached; including the name and address of your personal healthcare provider.

ATTESTATION

Continuing Medical Education (CME/CE/CNE): I hereby certify within the past two years I have completed the requisite number of CME/CE/CNE hours prescribed by the State Medical Board of Ohio or applicable licensing authority. If audited I will be able to provide documentation of the seminars or courses attended. I recognize that failure to produce documentation upon request will jeopardize my membership and/or clinical privileges on the medical staff or allied health professional staff. Governing Documents: I hereby certify the Governing documents and policies have been made available to me at https://mchs.policytech.com/?anonymous=true&siteid=1, on the Medical Staff Credentialing category.

• Medical Staff Bylaws • Medical Staff Credentials Policy • Allied Health Professional Policy • Fair Hearing Policy • Medical Staff Organization Policy • Medical Staff Rules and Regulations • Medical Staff and AHP FPPE and OPPE Policy • Zero Harm Training Resolution for Physicians and AHPs • Medical Staff Code of Conduct • Mount Carmel Privacy - Security Brochure

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It is important that you review the policies listed below as Mount Carmel continues to strengthen our medical administration program and to provide high-quality, safe care to every patient.

• MCHS Emergency and Override Drug List • High-Risk CNS Medications • Terminal Ventilator Withdrawal Key Points • Palliative Ventilator Withdrawal Policy

I agree that if I am granted Medical Staff Appointment and/or Privileges at a Hospital(s) in the Mount Carmel Health System, I shall abide by these documents and all other applicable documents including, without limitation, the Hospital’s code of regulations and Medical Staff and Hospital policies, as such documents and policies may change from time to time, that may apply during the entire period of my Medical Staff appointment and/or Privileges. I further agree to be bound by the confidentiality, immunity and release of liability provisions in the Medical Staff Bylaws/Policies and the obligation to exhaust all administrative remedies provided by the Medical Staff Bylaws/Policies before resorting to legal action. I further agree to provide the MCHS hospital(s) with thirty (30) days prior written notice should I choose to resign my Medical Staff appointment and/or Privileges. Burden of Producing Information. I understand I have the burden regarding the following:

• Producing information deemed adequate by Mount Carmel Health System for a proper evaluation of my qualifications for Medical Staff Appointment and/or Privileges, and for resolving any concerns of the applicable Medical Staff(s) or Hospital(s).

• Appearing for personal interviews, if required. • Providing a complete application, including adequate responses from references and evidence that

all of the statements made and information given on the application are accurate and complete. • An application shall be deemed complete when all questions on the application form have been

answered, all related documentation has been supplied, and all information has been appropriately verified.

• Resolving any reasonable doubts with respect to my application and satisfying reasonable requests for information including submission to a medical or cognitive examination by a provider of Mount Carmel Health System’s choice, at my expense, if deemed appropriate for the Privileges requested.

Reporting Requirements: I understand and agree that if my Medical Staff Appointment and/or Privileges are denied based upon my conduct or competence, I may be subject to reporting to the National Practitioner Data Bank and/or applicable state authorities. Medical Staff Obligations: I acknowledge my responsibility to satisfy the obligations of Medical Staff Appointment and/or Privileges. Notification Requirements: I agree to notify the Medical Staff President or appropriate Vice President of Medical Affairs immediately if any information contained in my application or this addendum changes. I further agree that the foregoing obligation shall be a continuing obligation so long as I hold a Medical Staff Appointment and/or Privileges at MCHS hospital(s). Any material misstatement(s) in or omission(s) from the application (or this addendum) constitutes grounds for denial of the application without entitlement to any hearing or appeal rights except for the limited purpose of resolving any dispute as to the actual facts. For your protection sign as you would sign official hospital documents. ________________________________________________ ____________________________ Signature Date ________________________________________________ Name (PLEASE PRINT)

MOUNT CARMEL HEALTH SYSTEM

Mount Carmel Grove City, East, St. Ann's, and New Albany Surgical Hospitals a Member of Trinity Health

RELEASE OF INFORMATION / STATEMENT OF APPLICANT

By applying to the Mount Carmel Health System Credentialing Verification Office (“CVO”) for Medical Staff appointment/reappointment and/or Privileges at Mount Carmel Health (East or West), Mount Carmel St. Ann’s Hospital, and/or Mount Carmel New Albany Surgical Hospital (“Hospital” or “Hospitals”), as listed on my application, I hereby:

Acknowledge that as a condition of submitting an application for appointment/reappointment and/or Privileges, I have a responsibility to read and understand the Medical Staff Bylaws, Manuals, and Rules and Regulations of the Hospital(s), and to be bound by the terms of such documents and all other applicable Medical Staff and Hospital policies, as may from time to time be in effect, as they relate to my application as well as to any grant of appointment and/or Privileges. I further acknowledge that such documents have been made available to me.

Acknowledge my responsibility to satisfy the obligations of Medical Staff appointment and Privileges at Hospital(s) including, without limitation, conducting my practice in accordance with the ethical principles of my profession. Understand that I have the burden of: - Producing information deemed adequate by the CVO and Hospital(s) for a proper evaluation of my professional competence,

conduct, character, ethics, and other qualifications for appointment and/or Privileges, and for resolving any concerns of the CVO and Hospital(s) about such qualifications.

- Appearing for personal interviews, if required. - Providing a complete application including, without limitation, adequate responses from references and evidence that all of the

statements made and information given on the application/addendum are accurate and complete. - Resolving any reasonable doubts with respect to my application and satisfying reasonable requests for information including

submission to a medical or cognitive examination by a provider of the CVO’s and Hospital(s)’ choice, at my expense, if deemed appropriate for the Privileges requested.

Understand and agree that no action will be taken on this application/addendum until it is complete and all outstanding questions with respect to the application/addendum have been resolved to the CVO’s and/or Hospital(s)’ satisfaction. Understand that, upon request, I will be informed of the status of my credentialing application. Provided that my application is deemed complete, I understand that I will be informed in writing by the Hospital(s) to which I am applying of the Board’s decision. I also understand that acceptance or rejection of this application is solely within the discretion of the Hospital(s). Understand that Mount Carmel Health System has a policy whereby information on healthcare providers, including peer review information, is shared among the Hospital(s) and related healthcare entities. Authorize representatives of the CVO and/or Hospital(s) to consult with administrators and members of the medical staffs of other health care institutions with which I have been associated and with other health care and/or related entities including, without limitation, past and present malpractice carriers, which may have information bearing upon my application. I hereby further consent to the inspection by representatives of the CVO and/or Hospital(s) of all documents that may be material to an evaluation of my professional qualifications and competence to carry out the Privileges requested as well as my moral and ethical qualifications for appointment to the Hospital(s)’ Medical Staff(s). I authorize all other health care entities and institutions with whom I have been associated, and their representatives, to provide all information and documentation requested including, without limitation, peer review information concerning me to the CVO and/or Hospital(s) upon request and agree to sign such release of information consent forms as may be necessary.

Authorize all educational institutions, consumer reporting agencies and any local, state or federal law enforcement or other government agencies or political subdivisions to supply information concerning my background to the CVO and/or Hospital(s) and to execute such releases as are necessary in order to obtain such information.

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Authorize the CVO and/or Hospital(s) to report, release, obtain, and exchange information with the Secretary of the Department of Health and Human Services, the applicable state licensing board, the Drug Enforcement Administration, the Federation of State Medical Boards, and specialty board certification bodies, relating to the following: (1) any payments made for my benefit under a policy of insurance, self-insurance, or otherwise in settlement or partial settlement of, or in satisfaction of a judgment in, a medical malpractice action or claim; (2) any professional review action or formal disciplinary procedure that in any manner adversely affects/affected my clinical privileges; (3) any surrender of clinical privileges relating to possible or alleged incompetence or improper professional conduct or any surrender of my clinical privileges accepted by a health care entity in return for not conducting such investigation or proceeding; (4) any professional review action of a professional society that adversely affects/affected my membership in the society; and (5) any revocation of my license or censure, reprimand, suspension or probation by any applicable licensing board of any state.

Release and grant absolute immunity to the CVO and Hospital(s), and their subsidiaries, affiliates, all entities with which Mount Carmel Health System and its subsidiaries and affiliates contract, and all directors, officers, employees, agents, independent contractors, Medical Staff members and any other individuals acting on behalf of any such entities from any liability whatsoever arising, directly or indirectly, from providing or obtaining information concerning me or otherwise acting upon my application provided they do not act upon the basis of false information knowing it to be false. Release and grant absolute immunity to all third parties, and their directors, officers, employees, agents, independent contractors, medical staff members and any other individuals acting on behalf of any such entities from any liability whatsoever arising, directly or indirectly, from providing information concerning me to the CVO and Hospital(s) provided they do not act upon the basis of false information knowing it to be false. Agree to otherwise be bound by the (a) confidentiality, immunity and release of liability provisions in the Hospitals’ Medical Staff Bylaws/Manuals; and (b) the obligation to exhaust all administrative remedies provided by the Medical Staff Bylaws/Manuals before resorting to legal action.

Understand and agree that this authorization, consent and release is irrevocable (a) for so long as I am an applicant for or hold a Medical Staff appointment and/or Privileges at the Hospital(s); or, (b) for as long as the CVO and/or Hospital(s) may be under a duty to report information regarding me pursuant to the Health Care Quality Improvement Act of 1986, 42 U.S.C., Sections 11101, et seq. (“HCQIA”) or pursuant to applicable state law. Understand and agree that this authorization, consent, and release allows the CVO and/or hospitals to provide information and documentation to other departments within Mount Carmel Health System, and other healthcare entities (whether within or outside of Mount Carmel Health System) that perform functions similar to the CVO. Understand and agree that information and documentation provided by the CVO and/or Hospital(s), as authorized by this consent, to any other health care entity (whether within or outside of the Mount Carmel Health System) shall not constitute a waiver of Ohio’s peer review privilege. Agree to notify the Medical Staff President or appropriate Vice President of Medical Affairs immediately if any information contained in my application or addendum changes. I further agree that the foregoing obligation shall be a continuing obligation so long as I hold a Medical Staff appointment and/or Privileges at the Hospital(s).

Acknowledge that all information submitted by me in my application/addendum is true and complete to my best knowledge and belief. I fully understand that any material misstatement(s) in or omission(s) from my application/addendum may constitute cause for denial of appointment/reappointment, Privileges, or dismissal from the Hospital(s) Medical Staff(s).

A photocopy of this waiver shall be as effective as the original when so presented. I certify that the attached is a current photograph of me and I acknowledge that it will be used to verify my identity.

Signature: _____________________________________________________ Date:_______________________________

Printed Name: ___________________________________________________

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Confidentiality and Information Security Agreement The following rules for Confidentiality and Information Security apply to all non-public patient and business information (“Confidential Information”) of Trinity Health and all of its affiliated and controlled healthcare organizations. The rules also apply to the non-public and business information of joint ventures, and other entities and persons collaborating with Trinity Health, to which an authorized user has access to Trinity Health’s computer system, network or application (“Computer System”) containing Confidential Information.

As a condition of being permitted to have access to Confidential Information on Trinity Health’s Computer System which is relevant to my job function or role, I agree to comply with Trinity Health's posted policies and procedures, including the following rules:

1. Permitted and Required Access, Use and Disclosure of Confidential Information:

• I will access, display, store, use or disclose confidential Protected Health Information (PHI) only for legitimate purposes of diagnosis, treatment, or obtaining payment for patient care or for healthcare operations permitted by HIPAA.

• I will access, use or disclose Confidential Information only for legitimate business purposes of Trinity Health. • I will disclose confidential information only to individuals who have a need to know to fulfill their job

responsibilities and business obligations (e.g., co-workers, business associate). • I will only access, use or disclose the minimum necessary amount of confidential information needed to

carry out my job responsibilities or role. • I will protect all confidential information to which I have access, or which I otherwise acquire, from loss, misuse,

alteration, a modification or unauthorized disclosure and access including, but not limited to, the following: o making sure that paper records are not left unattended in unsecure areas where

unauthorized people may view them; o using password protection, screensavers, automatic time-outs and/or other appropriate

security measures to ensure that no unauthorized person may access confidential information from my workstation or other device;

o appropriately disposing of confidential information in a manner that will prevent a breach of confidentiality and never discard paper documents or other materials containing confidential information in the trash unless they have been shredded;

o safeguarding and protecting workstations and portable electronic devices containing confidential information including laptops, smartphones, tablets, CDs, USB thumb drives, etc.; and

o Ensure physical security of workstations. • I will ensure that any confidential information that is transmitted using the Internet or other public networks

is sent over a secure connection like VPN (That is, do not access, use or disclose confidential information at a hotel, Panera Bread, etc.).

• I agree to remove or delete confidential information when it is no longer needed. • I understand that my access to Trinity Health’s computer system is a privilege and not an absolute individual

right. • I will comply with Trinity Health's Enterprise Information Security and Privacy policies and procedures.

2. Prohibited Access, Use and Disclosure of Confidential Information: I will not access, display, store, use or disclose confidential information in electronic, paper or oral forms for personal reasons, or for any purpose not permitted by Trinity Health policies and procedures, including information about co-workers, family members, friends, neighbors, celebrities, or myself**.

• I will not engage in any activity that attempts to circumvent or avoid information security controls.

** NOTE: I will follow the required procedures at each applicable Ministry Organization regarding gaining access to my own PHI in medical and other records.

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• I will not share / disclose my own login ID, password, or other security device with any other person, including but not limited to, co- workers, supervisors, subordinates, family members, friends, etc. for any reason.

• I will not use another person’s login ID, password, other security device or other information that enables access to Trinity Health's Computer System.

• If my employment or association with Trinity Health ends, I will not subsequently access, use or disclose any Trinity Health confidential information and will promptly return any security devices and other Trinity Health property.

• I will not at any time or in any manner, either directly or indirectly, access confidential information for purposes of distributing, selling, marketing or commercializing Trinity Health confidential information for personal gain.

• I will not engage in any personal use of Trinity Health’s Computer Systems that inhibits or interferes with the productivity of colleagues or others associated within Trinity Health’s business operations, or that is intended for personal gain.

• I will not at any time or in any manner use by access to create derivative products or applications based on Trinity Health’s confidential information.

• I will not utilize the Trinity Health computer system to access Internet sites that contain content that is inconsistent with the mission, values, policies, and procedures of Trinity Health.

• I will not misuse or attempt to alter Trinity Health’s Computer System in any way. • I will not carelessly utilize an Internet capability that may negatively impact Trinity Health’s Computer System

normal performance or unduly jeopardize network computing capabilities and resources, including causing them to malfunction regardless of location or duration.

• I understand that scanning of the network is prohibited when it is not within the scope of your job function or role.

• I understand that sharing network and/or application accounts (including work email accounts) is not permitted. • I will not willfully introduce a computer virus or other destructive program into Trinity Health’s Computer

System, including vendor/supplier computer systems and networks. • I will not automatically forward email to an external destination (i.e., personal email accounts) not

specifically approved by Trinity Health policy, procedure, administration, or department management. • I will not use Trinity Health’s Computer System or email for solicitation or for non-Trinity Health

commercial endeavors not specifically approved by Trinity Health policy, procedure, administration, or department management.

• I will not send unsolicited mass email messages, including the sending of “junk mail” or other advertising material (e.g., email spam), over Trinity Health’s computer system.

• I will not send bulk emails to non-Trinity Health recipients revealing the identity of the recipients (e.g., instead I will use 'blind copy' functionality)

• While utilizing Trinity Health’s Computer System, I will not engage in the transmission of information which is demeaning, defaming, harassing (including sexually) or disparaging to others based on race, national origin, sex, sexual orientation, age, disability or religion, or which is otherwise offensive, inappropriate and/or in violation of the mission, values, policies or procedures of Trinity Health.

• I will not access, display, store or distribute any offensive, discriminatory, or pornographic materials on Trinity Health’s Computer System.

• I will not use Trinity Health’s Computer System to create an intimidating or hostile work environment. • I will not use Trinity Health’s Computer System to commit fraud or use it unethically. Examples of fraud and

unethical use include, but is not limited to, the following: o misrepresenting oneself, or inappropriately representing Trinity Health; o any misrepresentation / fraud to gain unauthorized access to a Computer System; o unauthorized decrypting or attempting to decrypt the Computer System; o using an account of another individual without the latter’s express permission or proxy. o solicitation that is not specifically approved by Trinity Health policy, procedure,

administration, or department manager; and o participating in non-Trinity Health sponsored contests, games, or on-line gambling.

3. Use of Trinity Health Computer Systems/Devices:

• I understand that I am accountable for my use of Trinity Health’s Computer System, including, but not limited to, my content, emails and Internet use.

• I will immediately notify the Trinity Health’s Security Official or Privacy Official if I believe that there has been improper/unauthorized access to Trinity Health’s Computer System or improper use or disclosure of confidential information in electronic, paper or oral forms.

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• I understand that I am required to immediately report lost or stolen devices containing Trinity Health Confidential Information to TIS Service Desk at 888-667-3003 I understand that if I violate any of the requirements of this agreement, I may be subject to disciplinary action, my access may be suspended or terminated and/or I may be liable for breach of contract and subject to substantial civil damages and/or criminal penalties.

4. Trinity Health Monitoring and Disclosure to Third Parties / Law Enforcement:

• I understand that Trinity Health has the right to access and will Monitor my access to, and my activity within, Trinity Health’s Computer System.

• I understand that I have no rightful expectation of privacy regarding my access or activity within Trinity Health’s Computer System, including, but not limited to, any and all email messages sent or received from the same (e.g., personal email accounts).

• I understand that Trinity Health may disclose, as it deems necessary, my activity and any of my content on Trinity Health’s Computer System to law enforcement officials and to management without my consent / authorization or prior notice to me.

• I understand that if I violate any of the requirements of this agreement, I may be subject to disciplinary action, my access may be suspended or terminated and/or I may be liable for breach of contract and subject to substantial civil damages and/or criminal penalties.

5. Appropriate Software Use:

• I agree to use only Trinity Health approved software to conduct Trinity Health business. • I understand that my use of the software on Trinity Health’s Computer System is governed by the terms of

separate license agreements between Trinity Health and the vendors of that software. • I agree to use such software only to provide services to benefit Trinity Health. • I will not attempt to download, copy or install the software on any computer or other Trinity Health device. • I will not make any change to any of Trinity Health’s computer systems without Trinity Health’s prior express

written approval. • I will not make any unauthorized reproduction of information system software. • I agree not to violate any copyright or intellectual property rights laws.

6. Appropriate Network Use:

• I understand that access to Trinity Health’s Computer System is “as is”, with no warranties and all warranties are disclaimed by Trinity Health.

• I understand that Trinity Health may suspend or discontinue access to protect the Computer System or to accommodate necessary down time.

• I understand that in an emergency or unplanned situation, Trinity Health may suspend or terminate access without advance warning.

7. Termination of User’s Access to Trinity Health’s Computer System:

• Trinity Health, in its sole discretion, has the absolute right to terminate this agreement and the user’s access and use of confidential information at any time, with or without notice, for any reason or no reason without any damages or liability to you.

8. Employer Acceptance of Responsibility for an Individual with Access to Trinity Health’s Computer System

containing Confidential Information:

(Applies to physicians/physician practices; other individual or facility providers; a business associates; vendors; payers; any other unaffiliated organizations).

• I accept responsibility for all actions and/or omissions by my employees and/or agents. • I agree to notify the TIS Service Desk at 888-667-3003 within 5 business days if any of my employees or

agents no longer need or are eligible for access due to leaving my practice/company, changing their job duties or for any other reason.

• I agree to complete an annual review of all employees and agents in an effort to identify individuals who no longer need access.

• I agree to report any actual or suspected privacy or security violations made by my employees and/or agents to Trinity Health’s Privacy Official or Security Official.

• I understand that Trinity Health may terminate my employee and/or agent’s access, with or without prior notice to anyone, at any time.

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SIGNATURE PAGE / RELATIONSHIP TO TRINITY HEALTH / MINISTRY ORGANIZATION

I am a: (Please check all that apply to you)

Direct relationships with (Mount Carmel) Colleague (employee) at (Mount Carmel) Physician Credentialed on (Mount Carmel) Medical Staff Volunteer at a (Mount Carmel) Facility Temporary/Contractor at a ( Mount Carmel)/ Facility: (name of agency) Student at (Mount Carmel): (name of educational organization)

Employed by or Associated with a (Mount Carmel) Credentialed Medical Staff Member _Medical Staff Member’s Employee or Temp Staff (name of practice) Medical Staff Member’s Vendor’s Employee (name of vendor)

Vendor Providing Goods or Services to (Mount Carmel) Employee/Temp Staff of (Mount Carmel)’s clinical services vendor: (name of vendor) Employee/Temp Staff of (Mount Carmel)’s business services vendor: (name of vendor) Employee/Temp Staff of (Mount Carmel)’s IT services vendor: (name of vendor)

(Mount Carmel)’s Joint Venture or a Facility Managed by (Mount Carmel) Employee of a (Mount Carmel)’s Joint Venture (name of joint venture :) Employee of a Hospital/Other Facility Managed by (Mount Carmel) (name of facility): Credentialed Physician on Medical Staff of a Hospital/Other Facility Managed by (Mount Carmel):

(Name of facility): Employee or Temp Staff of a Credentialed Physician on the Medical Staff of a Hospital/Other Facility Managed by

(Mount Carmel): (name of physician’s practice)

Other Unaffiliated (non-credentialed) Physician/Other Provider: (name of practice) Employee of an Unaffiliated Physician or Facility: (name of practice or facility) Employee of a Payer :( name of payer) Researcher (Research study name): Other (name of employer)

USER SIGNATURE

If there are any items in this agreement that I do not understand, I will ask my supervisor or other appropriate (Mount Carmel) contact person for clarification. My signature below acknowledges that I have read, understand and accept this agreement and realize it is a condition of my employment or association with Trinity Health. I also acknowledge that I have received a copy of this Confidentiality and Network Access Agreement.

Print Name: ___________________________________________________________________________________

Signature of individual to be given access: ____________________________________________Date:___________

EMPLOYER SIGNATURE (Required when user is an employee or agent of a physician/physician practice; other individual or facility provider; a vendor that is not a business associate; any other organization unaffiliated with (Mount Carmel) or Trinity Health. My signature below acknowledges that I have read, understand and accept my responsibilities as the employer or the sponsor of the user who has signed this agreement above.

Print Name: ___________________________________________________________________________________

Signature of individual to be given access: ____________________________________________Date:___________

\\Mcehemcshare\mchs cvo$\Initial Application\Initial Application Packet\Disclosure Conflict of Interest Statement.doc 7-7-2015

A Member of Trinity Health

DISCLOSURE/CONFLICT OF INTEREST STATEMENT

The purpose of this form is to disclose any interest or affiliations you or a family member may have that may create a conflict of interest, based upon your position at Mount Carmel Health System (MCHS). I hereby state that I, or a member of my family, have the following affiliations or interests that might possibly constitute a conflict of interest:

1. Business Relationship with MCHS:

Please identify and describe any business arrangements you or a family member have with MCHS, its affiliates and its subsidiaries.

2. Relationships External to MCHS:

Please describe any employment or other relationship(s) you have with an organization that has a business or other relationship with MCHS or its subsidiaries (including consulting activities, governance/directorship appointments, etc.).

3. Outside Activities:

Please identify any outside activities in which you or a family member participates which might constitute a conflict of interest (example: holding a position as an officer, director or consultant to a business entity providing or receiving products or services to/from MCHS).

I agree to immediately inform MCHS Credentialing Verification Office (CVO) as appropriate, of any changes in my personal or family member's circumstance relative to conflict of interest which may occur prior to completion of my next annual disclosure statement. I understand that if I terminate my employment or association with Mount Carmel Health System that I will not share any business information that I had access to and acknowledge that legal action may result if I do so. I understand that the contents of this document will be treated as confidential information accessible only to Mount Carmel's governing board as necessary to determine the existence of a conflict of interest on my part or on the part of a member of my family.

INTEGRITY & COMPLIANCE / CODE OF CONDUCT

I am aware of and understand that it is my responsibility to follow the MCHS Code of Conduct in regard to the Integrity & Compliance Program. I further understand that if I engage in conduct that violates these policies, I will be subject to discipline up to and including termination. I understand that the Mount Carmel Code of Conduct is available to me through the Integrity & Compliance Department or on website http://insight.co.trinity-health.org/icp.

Name: (Please print) _______________________________________________ Signature: Date:

Application for System Access for Physicians, Offic e Staff and Authorized Contractors for Medical Practices

Business Fax NumberBusiness Fax Number

Date of Birth (MM/DD)*Date of Birth (MM/DD)* Last Four Digits SSN*Last Four Digits SSN*

First Name* First Name* MI MI Last Name*/Title Last Name*/Title

Ohio License NumberOhio License Number

NPINPI

Office Address* (Contractors enter practice then employer)Office Address* (Contractors enter practice then employer)

Office Telephone Number*Office Telephone Number*

City* (Practice then employer) City* (Practice then employer) State*State* Zip Code*Zip Code*

DEADEA

Practice Name* (Contractors enter practice then employer)Practice Name* (Contractors enter practice then employer)

First and Last Name of Physician Office ManagerFirst and Last Name of Physician Office Manager Office Manager E-mail AddressOffice Manager E-mail Address

DEA SchedulesDEA Schedules

Current Patient TreatmentCurrent Patient Treatment CodingCoding BillingBilling SchedulingScheduling RegistrationRegistration OtherOther

Reason for Requesting Access* - Select All That Apply

REQUESTOR'S HOME INFORMATION

Please complete the request form below and fax to (614) 234-9232. An asterisks or "*" denotes a required field. For assistance, please contact the Physician Information Help Desk at (614) 234-8999.

VERIFICATION OF REQUESTOR AUTHORITY AND IDENTITY

Primary Phone Number*Primary Phone Number*

REASON FOR REQUESTING ACCESS

REQUESTOR'S OFFICE INFORMATION

I AM REQUESTING ACCESS TO THE FOLLOWING APPLICATION (S) - SELECT THOSE THAT APPLY*

Centricity/PACSCentricity/PACS

PowerChartPowerChart

Application for System Access Print and Fax

NextGenNextGen

11/28/2018

New UserNew User Existing UserExisting User

Specify New or Existing User*

User Role* Staff PhysicianStaff Physician Non-Staff PhysicianNon-Staff Physician

Physician Office EmployeePhysician Office Employee

ResidentResident

CNPCNP PAPA OtherOther

EMail Address*EMail Address*

ImprivataImprivata

Certificate to Prescribe (CTP)Certificate to Prescribe (CTP)

Category PrivilegeCategory Privilege

DragonDragon

Behavioral Med PavilionBehavioral Med Pavilion

RNRN MAMA

None FullLevel of Prescriptive Authority Requested*:Level of Prescriptive Authority Requested*: None Full

AccessMC SurgiNet or ScheduleAccessMC SurgiNet or Schedule

ConnectConnect

AthenaAthena

PowerScribePowerScribe

VitreaVitrea

AccessMCAccessMC

HaloHalo

OtherOther

SurgiNet ResourceSurgiNet Resource

CRNACRNA CNMCNM

CNSCNS CAACAA

StudentStudent

NCH PavilionNCH Pavilion

NODC Pyxis Application Users APNODC Pyxis Application Users AP

CO01 Citrix Cardiology AP UCO01 Citrix Cardiology AP U

CO01 Citrix Gastro AP UCO01 Citrix Gastro AP U

CO01 Citrix FetaLink All Sites AP UCO01 Citrix FetaLink All Sites AP U

CO01 Citrix XLTEK AP UCO01 Citrix XLTEK AP U

Hospital KeychainHospital Keychain

Group Mapping:

Cerner PowerChart Position:

Additional Comments?:

**************************************************Mount Carmel Use ONLY******************************* *******************

Enter your complete d number (d0000) or MCHS Network Login*Enter your complete d number (d0000) or MCHS Network Login*SpecialtySpecialty

New Privilege Applicant Letter

Dear Colleague: Assessing practitioner competency has always been the responsibility of medical staffs. In 2008, CMS mandated Focused Professional Practice Evaluation (FPPE) for any applicant granted new privileges and Ongoing Professional Practice Evaluation (OPPE) to assess ongoing competence. Because you are either a new applicant to our health system (welcome!) or an established practitioner requesting a new privilege (thank you for adding to our clinical expertise!), you will need to go through a period of focused review to be sure our patients always experience the safest care possible.

When you meet with your Department Chair to discuss your application, he or she will work with you to develop an FPPE plan. The plan will require an evaluator (supervising/collaborating physician for AHPs) to oversee your work for a specific number of cases. The oversight may involve direct observation, chart review, simulation lab experience, or interviews with staff you work with. The Plan will be submitted to the Credentials Committee with your application for approval. Most Plans are completed within six months.

The Department Chair will expect you to designate a person as your primary evaluator for the Plan and indicate his/her name and phone number below. For physicians, your evaluator can be a partner or someone who already has the privilege for which you are applying. For AHPs, it will be your primary supervising/collaborating physician. Please have your primary evaluator name ready at the time of your interview with the Department Chair. If you do not know someone who could evaluate you, the Department Chair will advise you. You may also have additional evaluators, but there must be one person responsible for completing your evaluation.

Once the Credentials Committee has approved your application and Plan, you will be given a packet including the forms necessary to complete the FPPE process. The packet will be emailed to you and will contain information to complete the forms. If you have any questions, please feel free to contact Medical Staff Services or the Credentials Verification Office 614-546-3540 or email CVO@mchs.com. Thank you, and welcome aboard!

Please complete and return to the CVO with your application packet:

Applicant Signature: Date:

Applicant Name:

Planned Primary Evaluator (please print): (Supervising/Collaborating physician for AHPs)

Evaluator Phone Number:

MCE ATTN: Medical Staff Services

6001 E. Broad St. Columbus, OH 43213

MCNA ATTN: Medical Staff Services

7333 Smith's Mill Rd. New Albany, OH 43054

MCSA ATTN: Medical Staff Services

500 S. Cleveland Ave. Westerville, OH 43081

MCGC ATTN: Medical Staff Services

5300 N Meadows Dr. Columbus, OH 43123

1 This Code of Conduct

Supplement for Medical Staff

2 This Code of Conduct is effective: March 1, 2018.

Code of Conduct – Supplement for Medical Staff

As a member of the medical staff of a Trinity Health hospital, you serve as a trusted partner in the delivery of health care services to our patients and community. The Trinity Health Mission Statement calls us to serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities. Guided by our Core Values, we are committed to the delivery of people-centered care that leads to better health care, improved health outcomes, and overall lower costs for our patients, residents, members and communities we serve.

Trinity Health has established a system-wide Integrity and Compliance Program to support all who work in our health care ministry in understanding and following the laws, regulations, professional standards, and ethical commitments that apply. The Trinity Health Code of Conduct describes behaviors and actions expected of all who work in Trinity Health – colleagues, physicians, suppliers, board members and others. This Supplement describes those areas of the Code of Conduct that have particular application to our relationship with you as a member of the hospital's medical staff. If you have any questions regarding this information, please contact your Medical Staff Office or the Integrity & Compliance Officer at your Ministry. The complete Code of Conduct is available online at http://www.trinity- health.org/documents/codeofconduct.pdf.

**** The following standards are expected of all clinical professionals who work in Trinity Health, including members the medical staff:

Professionalism

• Deliver people-centered, quality health care services with compassion, dignity and respect for each individual.

• Deliver services without regard to race, color, religion, gender, sexual orientation, marital status, national origin, citizenship, age, disability, genetic information, payer source, ability to pay, or any other characteristic protected by law.

• Maintain a positive and courteous customer service orientation. • Demonstrate the highest levels of ethical and professional conduct at all times and under all

circumstances. • Speak professionally and respectfully to those with whom you work and whom you serve. • Respond to requests for information or assistance in a timely and supportive manner. • Behave in a manner that enhances a spirit of cooperation, mutual respect, a supportive team

environment and trust among all members of the team.

3 This Code of Conduct is effective: March 1, 2018.

• Deliver services in accordance with all professional standards that apply to your position. • Create and maintain complete, timely and accurate medical records consistent with medical

staff bylaws. • Protect the privacy and confidentiality of all personal health information - electronic, paper or

verbal - you may receive. • Maintain appropriate licenses, certifications and other credentials required of your position. • Abstain from inappropriate physical contact or inappropriate behavior with others. • Report any harassment, intimidation or violence of any kind. • Maintain a safe work environment by performing your duties and responsibilities free from the

influence of drugs or alcohol. • Protect the confidentiality of all peer review information.

Commitment to Providing Quality Care that is Safe and Medically Appropriate

• Commit to safety: every patient, every time. • Speak up when you see a quality or safety issue and discuss mistakes you see with others so we

can learn how to prevent future mistakes. • Adhere to clinical guidelines and protocols that reflect evidence-based medicine. • Actively engage and support efforts to improve quality of care, including organization-approved

technology advancements. • Actively participate in initiatives to improve care coordination between and among caregivers,

community support agencies and other providers. • Actively participate in initiatives to improve the health of the community as a whole.

Advocating for Our Patient's Needs

• Provide comfort for our patients, including prompt and effective response to their needs. • Communicate clinical information to patients and their designees in a clear and timely manner. • Discuss available treatment options openly with patients, or their designees, and involve them

in decisions regarding their care. • Provide care to all patients who arrive at your facility in an emergency, as defined by law,

regardless of their ability to pay or source of payment. • Clearly explain the outcome of any treatment or procedure to patients, or their designees,

especially when outcomes differ significantly from expected results. • Respect patient advance directives. • Address ethical conflicts that may arise in patient care, including end-of-life issues, by consulting

your organization's medical ethics committee or Mission Officer. • Provide care that is consistent with the Ethical and Religious Directives for Catholic Health Care Services.

4 This Code of Conduct is effective: March 1, 2018.

Stewardship of Resources • Properly use and protect all resources including materials and supplies, equipment, staff time and

financial assets. • Respect the environment and follow your organization's policies for the handling and disposal of

hazardous materials and infectious waste.

Corporate Citizenship • Act with honesty and integrity in all activities. • Actively participate in training programs offered by your organization. • Follow your organization's policies requiring the disclosure of outside activities orrelationships that could

representa conflict of interest withyour medical staff membershipor role and any other responsibilities. • Follow all requirements of Medicare, Medicaid, other federal and state health care programs, as

well as those of commercial insurance companies and other third-party payers. These requirements generally involve:

o Delivering high-quality, medically necessary and appropriate services. o Creating and maintaining complete and accurate medical records. o Submitting complete and accurate claims for services provided. o Protecting the privacy and security of health information we collect.

• Conduct all medical research activities consistent with the highest standards of ethics and integrity and in accordance with all federal and state laws and regulations, and your organization's Institutional Review Board policies.

• Immediately notify your Medical Staff Office if notified you have been excluded or debarred from participation in federal or state health care programs.

Where to Find Help If you have a question or concern about possible violations of law, regulation or the Code of Conduct you are encouraged to seek answers by contacting one of the following resources:

• Your Chief Medical Officer or Medical Staff Office • Another member of your organization's senior management team • Your Ministry's Integrity & Compliance Officer • The Trinity Health Integrity and Compliance Line at 1-866-477-4661 or you may file a written

report online at www.mycompliancereport.com using access code "THO"

5 This Code of Conduct is effective: March 1, 2018.

Thank You! We appreciate your taking time to review this information and our commitment to carrying out our Mission with the highest standards of ethical behavior. Your dedication and support is critical to this important effort.

Katrina Trimble Vice President, Integrity & Compliance

614-546-4361

Cheryl Piatka Director, Corporate Compliance

614-546-4294

Christie Santa-Emma

Privacy Officer

614-546-3284

Tom Enneking

Information Security Officer

614-546-3668