APPLICATION FOR APPOINTMENT TO THE MEDICAL STAFF … · graduate training . Waiver of Liability for...

APPLICATION FOR APPOINTMENT TO THE MEDICAL STAFF

Ophthalmology

Location Date

IDENTIFYING INFORMATION

Last Name First Name Initial

Is there any other name under which you have been known? Name(s):

Date of Birth Birthplace (City/Country) Citizenship

Social Security # Gender Race/Ethnicity (voluntary)*

Office Address City State Zip Code Area CodeTelephone

Home Address City State Zip Code Area CodeTelephone

Fax # Email Address Office Contact / Ext. / Email

Practice Limited To / Specialty

Other Medical Interests In Practice, Research, Subspecialties, Etc. PREMEDICAL EDUCATION (Attach additional sheets if necessary.)

College or University Degree Honors

Address Date of Graduation

MEDICAL/PROFESSIONAL EDUCATION (Attach additional sheets if necessary.)

Medical/Professional School Degree Honors

Address Date of Graduation

INTERNSHIP/PGI (Attach additional sheets if necessary.)

Institution Address Dates

Type of Internship Special

Practitioners Responsible for Performance: Chief of Staff, Chairman of Departments, Others RESIDENCIES (Attach additional sheets if necessary)

Please list Fellowships, Residencies, Preceptorships, Teaching Appointments (indicate whether clinical or academic), Postgraduate Education in chronological order.

Institution

Location/Address Dates Program Director

Complete Successfully Yes No Type of Training Specialty If, “no”, please explain on separate sheet.

Institution



Institution



CONTINUING MEDICAL EDUCATION

On a separate sheet, list all postgraduate activities which you have attended, or for which you have received credit in the past two years

Furnish a list of scientific papers or essays you have written and a list of scientific meetings you have attended during the previous three years (to include reprints). This information may be included in the resume.

AFFILIATIONS (Current and Previous including Military Service)

Please list in chronological order with the most recent affiliations first, all institutions where you have or had affiliations during the past ten (10) years. This includes hospitals, surgery centers, institutions, corporations, military assignments, or government agencies. If more space is needed, attach additional sheet(s).

A. Current Affiliations (including Hospitals and Ambulatory Surgical Centers)

Name and Mailing Address of Institution City/State/Zip

Department Status (active, provisional, courtesy, temporary, etc.) Appointment Date





If you do not have hospital privileges, please explain (physicians without hospital privileges must provide written plan for continuity of care).

B. Previous Hospital and Other Affiliations (including Military Service)

Name, City and State Department

Dates Reason for Leaving







MEMBERSHIP IN PROFESSIONAL SOCIETIES

Are you a Member of the County Medical Association? YES NO Do you have an application pending? YES NO Do you intend to apply? YES NO If member past or present or applicant to other County, State or National Society, give name:

BOARD CERTIFICATION

Include certifications by board(s) which are duly organized and recognized by: • A member board of the American Board of Medical Specialties • A member board of the American Society of Anesthesiologists • A member board of the American Academy of Pain Management • A member board of the American Osteopathic Association • A board of association with equivalent requirements approved by the state

medical board • A board of association with the Accreditation Council for Graduate Medical

Education of American Osteopathic Association • Approved postgraduate training that provides complete training in that specialty

or subspecialty

Name of Issuing Board

Certificate Number Date Certified/Recertified

Expiration Date (if any)

Have you applied for board certification other than those indicated above? YES NO If so, list board(s) and Date(s):

If not certified, describe your intent for certification, if any, and date of eligibility for Certification on a separate sheet.

OTHER CERTIFICATIONS (e.g. Fluoroscopy, Pain Management, Radiography, etc.)

TYPE: NUMBER: EXP. DATE:

TYPE: NUMBER: EXP. DATE:

MEDICAL LICENSURES/ REGISTRATIONS/ CERTIFICATES

Medical License Number (DEA) Registration Number

Controlled Dangerous Substances Certificate (CDS) ECFMG (foreign medical graduates)

Medicare UPIN/National Physician Identifier (NPI)

ALL OTHER STATE MEDICAL LICENSES. List All Medical Licenses Now or Previously Held. (Attach additional Sheets if necessary.)

State: License # Expiration Date:



PRACTICE INFORMATION

Practice Name (if applicable) Department Name (If Hospital Based)

Primary Office Mailing Address City, State, Zip

Telephone Number Fax Number E-Mail address

Office Manager/Administrator

Telephone Number Fax Number E-Mail address

Name Affiliated with Tax ID Number Federal Tax ID Number

Secondary Office Mailing Address City, State, Zip

Office Manager/Administrator Telephone Number Fax Number


Tertiary Office Mailing Address City, State, Zip

Office Manager/Administrator Telephone Number Fax Number


PROFESSIONAL LIABILITY (Attach copy of professional liability policy or certification face sheet.)

Current Insurance Carrier Policy Number Original Effective Date

Mailing Address City/State/Zip

Per Claim Amount $ Aggregate Amount $ Expiration Date

Please explain any surcharges to your professional liability coverage on a separate sheet.

Please list all of you professional liability carriers within the past seven years, other than the listed above:

Name of Carrier Policy Number Dates





Mailing Address City/State/Zip PEER REFERENCES

List two professional references, preferably from your specialty area, not including relatives, current partners or associates in practice. If possible, include at least one member from the Medical Staff of each facility at which you have privileges.

NOTE: References must be from individuals who are directly familiar with your work, either via direct clinical observation or through close working relations.

Name and Title Address Telephone



WORK HISTORY

Chronologically list all work history activities since completion of post-graduate training (use extra sheets if necessary). This information must be complete. A curriculum vitae is not sufficient. Please explain any gaps on a separate page.

Current Practice Contact Name


Telephone Number Fax Number From (mm/yy) TO (mm/yy)

Name of Practice/Employer Contact Name



Name of Practice/Employer Contact Name



Attestation Questions If answer to any of the following questions is "YES", please give full details on separate sheet of paper

A. Has your license to practice medicine, Drug Enforcement Administration (DEA) registration or an applicable narcotic registration in any jurisdiction ever been denied, limited, suspended, revoked, not renewed, or subject to probationary conditions, or have you been fined or received a letter of reprimand – or is such action pending?

B. Have you ever been suspended, fined, disciplined, or otherwise sanctioned, restricted or excluded for reasons relating to possible incompetence or improper professional conduct by Medicare, Medicaid, or any other public program – or is such action pending?

C. Have you ever been denied, for possible incompetence or improper professional conduct, clinical privileges, membership, contractual participation or employment by any medical organization (e.g. hospital medical staff, medical group, Independent Practice Association (IPA), health plan, health maintenance organization (HMO), preferred provider organization (PPO), private payer (including those that contract with public programs), medical society, professional association, medical school faculty position or other health delivery entity or system, or have your clinical privileges, membership, participation, or employment at any such organization ever been suspended, restricted, revoked or not renewed – or is any such action pending?

D. Have you ever surrendered clinical privileges, terminated contractual participation or employment, or resigned from any medical organization (e.g. hospital medical staff, medical group, IPA, health plan, HMO, PPO, medical society, professional association, medical school faculty position or other health delivery entity or system) while under investigation for possible incompetence or improper professional conduct or in return for such an investigation not being conducted – or is any such action pending?

E. Has your membership or fellowship in any local, county, state, regional, national, or international professional organization ever been revoked, denied, limited, or not renewed – or is any such action pending?

F. Have you been denied certification / recertification, or has your eligibility status changed with respect to certification / recertification by a specialty board?

G. Have you ever been convicted of any crime (other than a minor traffic violation)?

YES NO YES NO YES NO YES NO YES NO YES NO YES NO

H. Do you presently use any drugs illegally? YES NO I. Have any judgments been entered against you, or settlements been

agreed to by you within the last seven (7) years, in professional liability cases, or are there any filed and served professional liability lawsuits/arbitrations pending against you?

YES NO

J. Has your professional liability insurance ever been terminated, not

renewed, restricted, or modified (e.g. reduced limits, restricted coverage, surcharged), or have you ever been denied professional liability insurance, or has any professional liability carrier provided you with written notice of any intent to deny, cancel, not renew, or limit your professional liability insurance or its coverage of any procedures?

K. Are you able to perform all the services required by your agreements with, or the professional staff bylaws of the Healthcare Organization to which you are applying with or without reasonable accommodation, according to accepted standards of professional performance and without posing a direct threat to the safety of patients?

YES NO YES NO

I HEREBY APPLY FOR APPOINTMENT

Signature Active Temporary

If Temporary, state reason why

PRIVILEGES DESIRED

� Dermatology

� Gastroenterology

� General Surgery

� Genito-Urinary

� Gynecology � Neurology � Neurosurgery � Ophthalmology

� Oral/Dental � Orthopedic � Otolaryngology � Pain Management � Plastics � Podiatric

� Other(Specify)

� Special Procedures (Specify)

� Specialty or Sub-Specialty Consultation (Specify)

ACKNOWLEDGEMENT STATEMENT

I fully understand that any significant misstatements in, or omissions from this application constitute cause for denial of appointment or cause for summary dismissal from the Medical Staff. All information submitted by me in this application is true to my best knowledge and belief. In making this application for appointment to the staff of this facility, I acknowledge that I have received and read the Bylaws, rules and regulations of the medical staff of this facility, and I am familiar with the principles and standards of the accreditation agencies for hospital(s) and the principles, standards and the ethics of the national, state and local associations that apply to and govern my specialty and/or profession, I agree to be bound by the terms thereof without regard to whether or not I am granted membership or clinical privileges in all matters relating to the consideration of my application for appointment to the staff, and I further agree to abide by such facility and staff rules and regulations as may be from time to time enacted. I hereby further authorize and consent to the release of information by this facility, or its medical staff, to other hospitals, medical associations and other interested persons on request regarding any information the facility and the medical staff may have concerning me as long as such release of information is done in good faith and without malice, and I hereby release from liability this facility and its staff for so doing. I understand and agree that I, as an applicant for medical staff membership, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics and other qualifications and for resolving any doubts about such qualifications. By applying for appointment to the staff I hereby signify my willingness to appear for the interviews in regard to my application, authorize the facility, its medical staff and their representatives to consult with administrators and members of medical staff of other hospitals, facilities or institutions with which I have been associated and with others, including past and present malpractice carriers, who may have information bearing on my professional competence, character and ethical qualifications. I hereby further consent to the inspection by the facility, its medical staff and its representatives of all records and documents, including medical records, at other hospitals, that may be material to an evaluation of my professional qualifications and competence to carry out the clinical privileges requested as well as my moral and ethical qualifications for staff membership. I hereby release from liability all representatives of the facility and its medical staff for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications and I hereby release from liability any and all individuals and organizations who provide information to the facility, or its medical staff, in good faith and without malice concerning my professional competence, ethics, character and other qualifications for staff appointment and clinical privileges, and I hereby consent to the release of such information. I am informed and acknowledge that federal and state laws provide immunity protections to certain individuals and entities for their acts and/or communications in connection with evaluating the qualifications of healthcare providers. I hereby release all persons and entities, including this Healthcare Organization, engaged in quality assessment, peer review and credentialing on behalf of this Healthcare Organization, from any liability they might incur for their acts and/or communications in connection with evaluation of my qualifications for participation in this Healthcare Organization, to the extent that those acts and/or communications are protected by state or federal law. I will not participate in any form of fee-splitting, rebates, commissions, bonuses, kickbacks or any other form of monetary gain given as a result of having made a patient referral. Moreover, I pledge myself to shun unwarranted publicity, dishonest money-seeking, and commercialism; to refuse money trades with consultants, practitioners, makers of surgical appliances and instruments, or others; to teach the patient his financial duty to the physician and to expect the practitioner to obtain his compensation directly from the patient; to make fees commensurate with the service rendered and with the patient's rights; and to avoid discrediting my associates by taking unwarranted compensation.

I have not requested privileges for any procedures for which I am not certified. Furthermore, I realize that certification by a board does not necessarily qualify me to perform certain procedures. However, I believe that I am qualified to perform all procedures for which I have requested privileges. My physical and mental health status has not changed and I am physically and mentally able to exercise the privileges which I have requested for the ensuing year. I am fully able to carry out the responsibilities of my appointment to the Medical Staff to perform the clinical duties and essential job functions with or without reasonable accommodations. I promise to notify the facility medical director immediately should I develop drug or alcohol dependence, should a malpractice claim be made against me, or should my hospital privileges be suspended, revoked, restricted, limited, terminated, denied or not renewed. A photocopy of this document shall be as effective as the original.

Date: Print Name:

Signature: Signature of Applicant

(Stamped Signature Is Not Acceptable)

The health status of this applicant is hereby confirmed as stated above. There are no health problems existing which would prevent him/her from performing the functions and procedures identified in this application. Appointment Recommended Appointment Not Recommended Appointment Deferred Active Temporary If Temporary, state reason why

Date Chairman, Medical Advisory Committee

Appointment Recommended Appointment Not Recommended Appointment Deferred Active Temporary If Temporary, state reason why

Date Chairman, Board of Directors

Reviewed and Updated:

Date

MAC

Applicant

CEO

Date

MAC

Applicant

CEO

Date

MAC

Applicant

CEO

Date

MAC

Applicant

CEO

Date Applicant

Attachments for Review:

Current Licenses

Copy of Workmen’s Compensation

certificate of coverage (if applicable) Photo ID Résumé Current out of state license(s) Current Copy of CV

N/A Copy of Current Malpractice Insurance

List of Privileges requested, signed CPR, ACLS, PALS Certification Current Letter of Verification of

NPDB DEA Certification ECFMG

Privileges at Local Hospital Verification(s) of licensure from State Licensure Boards (all states held)

List of Outpatient Privileges at Local Hospital

List of Continuing Education Activities

Certificates of completion from

Foreign Medical Graduate NA

Medical School, Anesthesia Training Program, Residencies, and Internships, or AMA verification Copy of certificates for formal postgraduate training Waiver of Liability for Release of Information

Reference Check Sheets

Two (2) Professional Sources not member of QI Peer Review N/A Initial Appointment

Copy of certificates for providing x- ray and laboratory services (if applicable) Primary Source Verification Job Description

� Medical Director � Anesthesia Director � Allied Health � Private Staff � CRNA

Confidentiality Statement

Addendum

Professional Liability Action Explanation

This Addendum is submitted to herein, this Healthcare Organization.

Please complete this form for each pending, settled or otherwise concluded professional liability lawsuit or arbitration filed and served against you, in which you were named a party in the past seven (7) years, whether the lawsuit or arbitration is pending, settled or otherwise concluded, and whether or not any payment was made on your behalf by an insurer, company, hospital or other entity. All questions must be answered completely in order to avoid delay in expediting your application. If there is more than one liability lawsuit arbitration action, please photocopy this addendum prior to completing and complete a separate form for each lawsuit.

Identifying Information

Last Name First Middle

Street Address City/State/Zip

Case Information

City, County, and State where lawsuit filed Court Case Number

Date of alleged incident Date Suit Filed Sex of Patient Age of patient

Location of incident: Hospital My office Other doctor’s office Surgery Center Other (please specify)

Your relationship to Patient (Attending Physician, Surgeon, Assistant, Consultant, etc.):

Allegation:

Is/was there an insurance company or other liability protection company or organization providing coverage/defense of the lawsuit or arbitration action? YES NO

If yes, please provide company name, contact person, phone number, location and carrier’s claim identification number of insurance company, or other liability protection company or organization.

If you would like us to contact your attorney regarding any of the above, please provide attorney(s) name(s) and phone number(s).

Please fax this document to your attorney as this will serve as your authorization:

Name: Phone Number ( )

Name: Phone Number ( )

What is the status of the lawsuit/arbitration described above (check one)

� Lawsuit / arbitration still ongoing, unresolved.

� Judgment rendered and payment was made on my behalf. Amount paid $

� Judgment rendered and I was found not liable.

� Lawsuit / arbitration settled and payment made on my behalf. Amount paid $

� Lawsuit / arbitration settled, no judgment rendered, no payment made on my behalf.

Summarize the circumstances giving rise to the action. If the action involves patient care, provide a narrative, with adequate clinical detail, including your description of your care and treatment of the patient. If more space is needed, attach additional sheet(s). Include 1) condition and diagnosis at the time of incident, 2) dates and description of treatment rendered, and 3) condition of patient subsequent to treatment. Please print.

SUMMARY

I certify that the information in this document and any attached documents is true and correct. I agree that “this Healthcare Organization”, its representatives, and any individuals or entities providing information to this Healthcare Organization in good faith shall not be liable, to the fullest extent provided by law, for any act or occasion related to the evaluation or verification contained in this document. In order for participating healthcare organizations to evaluate my application for participation, and/or my continued participation, in those organizations, I hereby give permission to release to this Healthcare Organization information about this lawsuit or arbitration. It is my understanding that the information provided will be maintained in a confidential manner and will be shared only in the context of legitimate credentialing and peer review activities. This authorization is valid unless it is revoked by me in writing. I authorize the attorneys listed above to discuss any information regarding this case with ‘this Healthcare Organization”.

As used in this Addendum, the term “this Healthcare Organization” shall refer to the entity to which this Addendum is submitted as identified above.

Print Name:

Date: Signature:

11811 North Dale Mabry (813) 961-8500 Tampa, FL 33618 (Fax) 968-6818

AUTHORIZATIONS AND RELEASES

Your signature signifies that you agree to the following conditions pertaining to this application.

1. I attest to the correctness and completeness of all information furnished.

2. I am willing to appear for interviews in connection with this application.

3. I agree to abide by the terms of any bylaws, rules, regulations, policies and procedure manuals of Tampa Bay Surgery Center as presently formulated or as later amended or modified.

4. I authorize a representative of Tampa Bay Surgery Center to consult associates

or others who may have information bearing on my qualifications and consent to their inspecting records and documents that may be material to the evaluation of my qualifications and competence.

5. I release from liability all those who, in good faith review, act on or provide

information regarding the competence, professional ethics, character, health status and other qualifications for clinical privileges.

6. I authorize any healthcare facility to release copies of my privileges and staff

application to Tampa Bay Surgery Center.

7. I authorize any medical school of healthcare facility to release any information on my medical training, internship, residency and fellowship.

8. I agree to provide the Medical Director of Tampa Bay Surgery Center of any

change in the information submitted in this application within 30 days of such change.

SIGNATURE PRINT NAME

DATE SOCIAL SECURITY NUMBER

CONFIDENTIALITY STATEMENT

The Governing Body and staff of the center deem confidentiality of Protected Health Information (PHI). PHI is any information, whether oral or recorded in any form or medium (a) that relates to the past, present or future physical or mental condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual; and (b) that identifies the individual, or with respect to which there is a reasonable basis to believe the information can be used to identify the individual.

The patient and the organization have the right to expect that PHI will be treated as confidential.

Strict confidentiality requirements are enforced to assure that medical records are used within this facility only by recipients authorized under HIPAA or authorized by the patient. Board and committee meeting minutes and facility business activities are kept strictly confidential.

Information, which is considered to be privileged, may not be released to anyone without the written authorization of the patient unless required by law.

Information which is considered non-privileged is that which has been de-identified, i.e., names, addresses, patient numbers, admission or procedure dates have been removed. However, discretion must be exercised in release of non-privileged information.

All employees will monitor facility compliance with HIPAA Confidentiality Standards in securing patient charts, work area safeguards and electronic security.

Prohibition on Sale of PHI

This organization will not accept remuneration for PHI without the individual’s authorization (unless it is to recoup the costs of providing data to a public health official, to a researcher, or to the individual himself, or meets certain other exceptions).

Restriction on Marketing

This organization will not send an individual marketing material and get paid for it, unless he authorizes it or she is taking the medicine being marketed.

This organization will not send an individual marketing materials for free, unless he authorizes it or the communication is made for certain purposes (e.g., to describe a product available in the health plan or to recommend alternative health care options).

Satisfaction of “Minimum Necessary”

Whenever sufficient to carry out the purpose for which PHI is being used or disclosed, this organization will use or disclose PHI in the form of a “limited data set.” This requirement is satisfied by removing names, street addresses, social security number and other identifiers. “Individually identifiable health information” is information, including demographic data, that relates to:

• the individual’s past, present or future physical or mental health or condition,

• the provision of health care to the individual, or

• the past, present, or future payment for the provision of health care to the individual.

Individuals’ Rights

• Electronic health records (EHRs), will be provided to the patient individual (or his designee) upon request with a copy of

the information in such EHR in electronic format.

• EHRs will be provided to the patient upon request with an account of disclosures of the information in his EHR during the

last three years, including disclosures made for treatment, payment or health care operations.

For covered entities who acquired an EHR after January 1, 2009, this requirement will apply to disclosures from such record made on or after January 1, 2011.

For covered entities who acquired an EHR on or before January 1, 2009, this requirement will apply to disclosures from such a record made on or after January 1, 2014.

This organization will honor the request of an individual not to disclose to his health plan the PHI related to a particular

treatment if the individual is paying for the full cost of the treatment out-of-pocket.

Business Associates shall enter into agreement with this organization to be notified whenever “unsecured” PHI is breached. Such notification shall be made without unreasonable delay and in any event within 60 days of discovery (or within 60 days of the date the breach should have been discovered). The notice must identify each individual whose unsecured PHI is breached. It should also contain the information necessary for the covered entity to satisfy its notification obligations with respect to each affected individual.

Violations of HIPAA regulations can result in sanctions against the medical staff members, employees and facility. Enforcement is handled through the United States Department of Health and Human Services (HHS), Office for Civil Rights. Information regarding sanctions can be found through their website at www.hhs.gov

I have read and understand the above confidentiality statement and recognize my obligation to safeguard records against unauthorized or inadvertent disclosures, loss, tampering, alteration or destruction. I, _________________________________ (name printed) understand this is condition of staff appointment and will make a concerted effort to protect the privacy and rights of all parties concerned.

This confidentiality statement will be retained in the appropriate Medical Staff/Human Resources Personnel File and signed annually.

Signature Date

Sign Here

http://www.hhs.gov/

CONFIDENTIALITY AGREEMENT

It is the responsibility of all employees, medical staff, allied health staff, students and volunteers, to preserve and protect confidential patient, employee and business information. The federal Health Insurance Portability Accountability Act (the “Privacy Rule”), as well as individual state codes govern the release of patient identifiable information by hospitals and other health care providers and the acquisition and use of data that pertains to individuals. All of these laws establish protections to preserve the confidentiality of various medical and personal information and specify that such information may not be disclosed except as authorized by law or the patient or individual. Confidential Patient Care Information includes: Any individually identifiable information in possession or derived from a provider of health care regarding a patient's medical history, mental, or physical condition or treatment, as well as the patients and/or their family members records, test results, conversations, research records and financial information. (Note: this information is defined in the Privacy Rule as “protected health information.”) Examples include, but are not limited to:

• Physical medical and psychiatric records including paper, photo, video, diagnostic and therapeutic reports, laboratory and pathology samples;

• Patient insurance and billing records; • Mainframe and department based computerized patient data and alphanumeric radio pager messages; • Visual observation of patients receiving medical care or accessing services; and • Verbal information provided by or about a patient

Confidential Employee and Business Information includes, but is not limited to, the following:

• Employee home telephone number and address: • Spouse or other relative names; • Social Security number or income tax withholding records; • Information related to evaluation of performance; • Other such information obtained from the patient’s records which if disclosed, would constitute unwarranted invasion of

privacy; or • Disclosure of Confidential business information that would cause harm to the Center.

Peer review and risk management activities and information are protected under the attorney-client privilege. I understand and acknowledge that:

1. I shall respect and maintain the confidentiality of all discussions, deliberations, patient care records and any other information generated in connection with individual patient care, risk management and/or peer review activities.

2. It is my legal and ethical responsibility to protect the privacy, confidentiality and security of all medical records, proprietary information and other confidential information relating to the Center and its affiliates, including business, employment and medical information relating to our patients, members, employees and health care providers.

3. I shall only access or disseminate patient care information in the performance of my assigned duties and where required by or permitted by law, and in a manner which is consistent with officially adopted policies of the Center, or where no officially adopted policy exists, only with the express approval of my supervisor or designee. I shall make no voluntary disclosure of any discussion, deliberations, patient care records or any other patient care, peer review or risk management information, except to persons authorized to receive it in the conduct of the Center affairs.

4. My user ID is recorded when I access electronic records and that I am the only one authorized to use my user ID. Use of my user ID is my responsibility whether by me or anyone else. I will only access the minimum necessary information to satisfy my job role or the need of the request.

5. I agree to discuss confidential information only in the work place and only for job related purposes and to not discuss such information outside of the work place or within hearing of other people who do not have a need to know about the information.

6. I understand that any and all references to HIV testing, such as any clinical test or laboratory test used to identify HIV, a component of HIV, or antibodies or antigens to HIV, are specifically protected under law and unauthorized release of confidential information may make me subject to legal and/or disciplinary action.

7. I understand that the law specially protects psychiatric and drug abuse records, and that unauthorized release of such information may make me subject to legal and/or disciplinary action.

8. My obligation to safeguard patient confidentiality continues after my termination of employment with the Center. I, , hereby acknowledge that I have read and understand the foregoing information and that my signature below signifies my agreement to comply with the above terms. In the event of a breach or threatened breach of the Confidentiality Agreement, I acknowledge that the Center may, as applicable and as it deems appropriate, pursue disciplinary action up to and including my termination. Signature Date

Sign Here

HEALTH STATEMENT

I, do hereby attest that my current mental and physical health status enables me to perform the clinical duties and essential job related functions with or without reasonable accommodations.

Physician Signature Date

HEALTH STATUS CONFIRMATION Dr. health statement has been confirmed to verify that no health problems exist which would prevent him/her from performing the functions and procedures identified in the request for appointment/re-appointment to the facility.

Reviewed By:

Signature of MAC Chairperson Date:

REFERENCE REPORT

Name MD DO DPM DDS CRNA

The above named practitioner has made application to the Staff of the Tampa Bay Surgery Center. Please complete all parts of this form evaluating the areas listed below as indicated for this applicant according to your best ethical and moral judgment. If more space is needed, please use an additional sheet.

I. VERIFICATION: Doctor was at from to .

II. EVALUATION: This evaluation should be based on demonstrated performance compared to that which is reasonably expected of a practitioner at his/her level of training, experience and background.

AREA FOR REVIEW POOR FAIR GOOD EXCELLENT CANNOT COMMENT

Basic Medical Knowledge Specific to privileges requested/specialty Professional Judgment/Responsibility Ethical Conduct Competence and Skill in specialty/ procedures to be performed and Patient Age Based Requirements

Cooperative/ability to work with peers Participation in committees and Medical Staff affairs Completion of medical records Patient Management Physician/Patient relationship Ability to understand, speak and write English Compliance with facility policies, program and medical staff bylaws, rules and regulations

Ability to work and communicate effectively with others

AREA FOR REVIEW YES NO CANNOT COMMENT

To your knowledge, has this practitioner ever been subject to any disciplinary action, such as admonition, reprimand, restriction of medical or surgical privileges, suspension or termination?

Did this physician ever attend patients while apparently under the influence of alcohol or drugs? To your knowledge, has this physician ever been a defendant in a medical malpractice action? To your knowledge, has this physician ever been a defendant in a felony criminal matter? Are you aware of any mental or physical problems with this physician? Does this applicant meet the requirements for reappointment to your staff?

III. RECOMMENDATIONS: 1. Applicant is qualified for privileges requested 2. Applicant is qualified for privileges requested with the following exceptions (please explain on back) 3. Applicant is NOT qualified for privileges requested

IV. What is the best time to contact you by telephone, should further information be needed?

Time: Telephone Number:

Completed by (Type or Print Name) : Title:

Signature Date

PLEASE MAKE ANY COMMENTS ON REVERSE (notable strengths/weaknesses, or explanation of above answers)

Tampa Bay Surgery Center PHYSICIAN PRIVILEGES

OPHTHALMOLOGY

Please check off which procedures you are requesting to perform in the surgery center. Requested Granted Procedure

Argon Laser Trabeculectomy Aspiration Of Aqueous Biopsy Blepharopigmentation Blepharoplasty Brow Lift Canthoplasty Capsulotomy Chalazion Excision Conjunctivoplasty - With Mucous Membrane Graft Conjunctivoplasty - With Sliding Graft Conjunctivoplasty - Without Graft Corneal Graft Corneal Ulcer Curretage Or Cauterization Cryopexy On Eyelashes Cryotherapy Cyclodialysis Cyclodiathermy Cyclotherapy - Minor Cyst Excision Dacrocystectoma Dacrocystorhinostomy Dacryceptectomy Dermatochalasis Repair Dilation/Probe/Irrigation - Under General Anesthesia Discission Ectropion Repair Entropion Repair Enucleation Epikeratophakia Epilation - Minor Evisceration Examination Under Anesthesia Excision Of Conjunctival Tumor Excision Of Lesion Excision Of Lesion With Reconstruction/Plastic Repair Excision Of Lesion With Skin Graft Excision Pterygium Extraction - Extra Capsular, Cataract Extraction - Intra-Capsular, Cataract

Tampa Bay Surgery Center PHYSICIAN PRIVILEGES

OPHTHALMOLOGY

Please check off which procedures you are requesting to perform in the surgery center. Requested Granted Procedure

Extraction With Iol Implant, Cataract Eye Muscle Resection Flap To Repair/Restore Anterior Chamber Fundoscopic Exam Goniopuncture Goniotomy Gundersen Flap Hordeolum Intubation With Silicone Tube Iridectomy Iridoplasty Iridotomy Iris Incarceration/Ulceration Irrigation And Drainage IV Sedation Keratectomy Keratomileusis Keratophakia Keratoprosthesis Keratoplasty - Lamellar Lacrimal Duct Probing And/Or Reconstruction Laser Capsulotomy Laser Photocoagulation For Branch Retinal Vein Occlusion - Macular

Laser Photocoagulation For Diabetic Retinopathy Laser Trabeculectomy LASIK Local Anesthesia Orbitotomy Parcentesis PRK Prophylaxis of retinal detachment Pterygium Ptosis Repair Punctum And Canailicular Exploration W/ Or W/O Plastic Repair Punctum Repair Radial Keratotomy Reformation Refractive Keratotomy Regional Blocks Removal Of Concretions - Minor Removal Of Superficial Foreign Body Removal/Reposition Of IOL Repair Of Dialysis

Tampa Bay Surgery Center

PHYSICIAN PRIVILEGES OPHTHALMOLOGY

Please check off which procedures you are requesting to perform in the surgery center.

Requested Granted Procedure Repair Of Laceration Repair Of Major Laceration Repair Of Marginal Laceration Repair Of Prolapse Repair Of Retinal Detachment Repair Of Wound Leak Repair Of Wound Or Extraocular Tendon Or Tendon's Capsule Repositioning/Removal/Exchange Of Iol Revision/Plastic Repair Of Socket Sclerotomy Sclerotomy - Partial Or Full Thickness - For Variety Of Glaucoma

Procedures Including Trabeculectomy Secondary Implantation Severing Tarsorrhaphy Strabismus Procedure Tarsorrhaphy Temporal Artery Biopsy Tension Measurement Therapeutic Retrobulbar Injections Trabeculectomy Transcleral Cryopexy Transcleral Diathermy Vitrectomy (Anterior Or Posterior Chamber) Yag Laser Capsulotomy Reading of specialty specific x-rays Other:

Physician Signature Date:

President/CEO Signature Date:

If other than President/CEO state reason.

Why:

Signature: Date:

* Additional pages attached � yes � no � N/A

Physician Orientation Informing Patient/Care Person of Serious Adverse Event

This organization has appointed a Patient Safety Officer to work with you and your patients in the event of a serious adverse event.

As the physician, it is your job to inform the patient and/or care person of the adverse event as soon as possible after the event occurs. In addition, you must also inform the patient and/or care person of all potential damage due to the adverse event.

Document the date and time that the patient and/or care person were informed of the serious adverse event, as well as all relative data, including notes of this interview, in the patient’s chart.

All adverse events are reported to the Risk Manager Designee and then to the Licensed Risk Manager through an Adverse Incident Report completed by the staff person involved in the incident. In the event that no staff person is directly involved in the adverse event, the staff person witnessing the event will complete the form. Each quarter, the Licensed Risk Manager will provide a report of all adverse events occurring that quarter which will be presented to the Board.

The following adverse/sentinel events are required to be reported to the State. They may also be required to be reported to your accrediting agency, but should be addressed with the accreditation agency on a per occurrence basis.

• Death • Brain Damage • Spinal Damage • Procedure performed on the wrong surgical site • Procedure performed on the wrong patient • Wrong procedure performed • Surgical procedure unrelated to the patient’s diagnosis • Surgical procedure to remove foreign objects remaining from a surgical procedure • Surgical repair of injuries from a planned surgical procedure

Involvement in any of the above listed adverse incidents required to be reported to the State will automatically initiate a Peer Review Process.

PROCESS FOR INFORMING THE CARE PERSON:

1. Request that the care person(s) be escorted to a private location for the disclosure conversation. 2. Request that at the least, one other person (i.e., the Patient Safety Officer or RM Designee) is in attendance to witness the

conversation. 3. Introduce (re-introduce) self and attending staff. 4. If possible, request that everyone be seated. 5. Remind the care person(s) of the original surgical/procedural plan and describe events, but not techniques, in lay terms leading up

to the adverse event. 6. Advise the care person(s) of the occurrence of the adverse event, as well as the result of the adverse event in a clear, concise

manner using simple, straight forward terms to the extent possible. 7. Anticipate possible upset and be empathetic. Be truthful and transparent. 8. Solicit and answer questions as straightforwardly as possible. 9. Discuss remedial actions and plan to include any financial considerations such as costs to cover the remedial plan. 10. Acknowledge the care person’s feelings and provide adjunct assistance as needed; i.e., other family members, minister. 11. Document events as discussed above.

PROCESS FOR INFORMING THE PATIENT:

1. Request that the patient be escorted to a private location for the disclosure conversation. 2. Determine patient’s level of recovery from anesthesia. 3. Review the original surgical/procedural plan and describe events, but not techniques, in lay terms leading up to the adverse event. 4. Disclose the occurrence and result of the adverse event, as well as any damages and corrective actions that are being or will be

taken in a clear, concise manner using lay terms to the extent possible. Speak simply and straightforwardly. 5. Advise patient that his/her care person(s) has/have been notified and when they will be reunited with them. 6. Briefly discuss remedial plan. 7. Document events as discussed above.

Signed: MD DO DPM DDS CRNA Date ___________

APPLICATION FOR APPOINTMENT TO THE MEDICAL STAFF … · graduate training . Waiver of Liability for...

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