APPLICATION FOR REAPPOINTMENT MEDICAL STAFF AND CLINICAL PRIVILEGES

FIRST_NAME LAST_NAME currently STAFFCATEG, DEPARTMENT

PLEASE REVIEW

Mass License, Federal DEA, Controlled Substance, Malpractice,

LICENSURE LIC_NO, DEA_NO, MACONTSUB, MALPRAC_NO,

LIC_EXP_DT DEA_EXP_DT MA_EXP_Date MALPRACEXP CMES PLEASE ATTACH LIST

DEMOGRAPHICS BUS_STREET BUS_CITY, BUS_STATE BUS_ZIP BUS_PHONE (tel) <BUS FAX> (fax) <PHYSICIAN EMAIL> CURRENT PRIMARY FACILITY AFFIALATIONS FACILITY STAFF CATEGORY

PLEASE FILL IN

PROFESSIONAL PEER REFERENCE (3 SAME SPECIALITY) NAME ADDRESS

PLEASE FILL IN

CATEGORY REQUEST (please specify Staff category desired)

ACTIVE CONSULTING COURTESY* * CLINICAL PERFORMANCE FROM PRIMARY INSTITUTION REQUIRED.

CATEGORY INFORMATION ACTIVE IS MORE THAN 12 PATIENTS COURTESY IS LESS THAN 12 PATIENTS YOUR CURRENT PATIENT ACTIVITY LEVEL IS ANSWER Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

NOTE Since your last reappointment or initial appointment to NERH, have any of the following ever been, or are actions pending, or are any currently in the process of being denied, revoked, suspended, reduced, limited, placed on probation, modified, not renewed, voluntarily or involuntarily relinquished, or have you ever withdrawn or failed to proceed with an application for any of the following: A Yes answers for all questions (except #15) require a written explanation on a separate sheet. Liability claims information should include names and dates or parties, clinical summary of events, disposition, current status and/or settlement amounts. Regardless of how #18 is answered, the application will be processed in the usual manner. If you have answered this question affirmatively and are found to be professionally qualified for medical staff appointment and the clinical privileges requested, you will be given an opportunity to meet with the Physicians Leadership to determine what accommodations are necessary or feasible to allow you to practice safely.

# 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

QUESTION Medical license in any state Other professional Registration DEA/Controlled substance registration Membership on any facility Medical Staff Clinical privileges Prerogatives/Rights on any Medical Staff Other institutional affiliation or status Professional society membership or fellowship/board certification or eligibility Any other type of professional sanction Professional liability insurance Individual focused review required by PRO or similar review agency Drivers License Have you been involved in any medical liability judgments, awards or out of court settlements, or is any malpractice action pending currently? If you answered Yes proceed to line 14. If you answered No, skip to question 15. Number in last two (2) years. Does your current liability insurance policy cover you for the privileges you have requested Do you have a physical or mental health condition, including alcohol or drug dependence, that could affect your ability to perform your duties and responsibilities as a member of the Medical Staff?** Have you been convicted of any crime, whether it be classified as a felony or misdemeanor, other than a minor traffic violation? Is there any additional information which may possibly influence your appointment to the Medical Staff of N. E. R. H. relating to the performance of your medical duties or reflect unfavorably upon your ability to interact with patients, hospital staff, or other members of the Medical Staff?

Yes No Yes No Yes No Yes No

In applying for reappointment to the Medical Staff of New England Rehabilitation Hospital, I certify that I am in good health, and have the physical and mental capabilities to carry out my duties and responsibilities as a member of the Medical Staff of New England Rehabilitation Hospital. I agree that I will at all times abide by the Bylaws, Rules & Regulations of the Medical Staff All information submitted by me in this application is true to the best of my knowledge and belief. In consideration of the Facility, I hereby release from any and all liability all representatives of the Facility and Medical Staff for any and all of their acts or statements at any time performed or communicated in good faith and without malice in connection with evaluating this application and my credentials and qualifications, and I hereby release from liability to the same extent 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, reappointment of clinical privileges, and I hereby consent to the release of such information. I hereby further authorize and consent to the release of information by this Facility, or its Medical Staff to other medical/dental/podiatric associations and other interested persons on request regarding any information the Facility and 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 Medical Staff for so doing. I further agree to report any changes in health status that would impact my ability to practice my profession at New England Rehabilitation Hospital, and will submit to a medical and/or psychological examination deemed acceptable by the Medical Executive Committee.

I WISH TO REMAIN A MEDICAL STAFF MEMBER OF NEW ENGLAND REHABILITATION HOSPITAL.

SIGNATURE ___________________________________________________________________ DATE____________________________________________________________

I DO NOT WISH TO REAPPOINTMENT. I FULLY UNDERSTAND THAT MY CURRENT MEDICAL STAFF MEMBERSHIP/PRIVILEGES AT NERH WILL EXPIRE AT THE END OF MY CURRENT APPOINTMENT.
SIGNATURE ___________________________________________________________________ DATE____________________________________________________________

ACKNOWLEDGEMENT, AUTHORIZATION AND RELEASE

_FIRST_NAME LAST_NAME Please Print Name Signature Date

ATTESTATIONS
CERTIFICATION OF FITNESS; PHYSICAL AND PSYCHOLGY EXAMINATION I, FIRST_NAME LAST_NAME), attest that no health problems exist that would adversely affect my ability to exercise the requested privileges and otherwise care for patients. Signature_____________________________________________________________________ Tuberculin Test/Tuberculosis Review
Have you experienced any of the following symptoms for more than 2 weeks?

Date ___________________________

Have you ever had a positive TB test in the past? Have you ever received the BCG vaccine? Have you ever been told you have TB? Have you ever received treatment for TB?

Yes* Yes Yes Yes

No No No No

*When was the date of your last CXR ______________________________ The undersigned confirms that all questions have been answered accurately. Print Name: FIRST_NAME LAST_NAME

Unexplained fever Unexplained weight loss Swollen glands Loss of appetite Night sweats Cough Bloody Sputum Chest Pain

Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No

Signature__________________________________________ Date ____________________

MEDICARE, CHAMPUS AND TRICARE ATTESTATION NOTICE TO PHYSICIAN: Medicare payment to hospitals is based in part on each patients principal and secondary diagnoses and the major procedures performed on the patient, as attested to by the patients attending physician by virtue of his or her signature in the medical record. Anyone who misrepresents, falsifies, or conceals funds, may be subject to fine, imprisonment, or civil penalty under applicable Federal laws. I, FIRST_NAME LAST_NAME, the undersigned, acknowledge having received the above notice. Signature_____________________________________________________________________ Date __________________________

CONTINUING EDUCATION ATTESTATION I, FIRST_NAME LAST_NAME), attest that I have completed the number of qualifying continuing education program hours required under my license and will provide additional information about my participation in continuing education programs upon request. Signature_____________________________________________________________________ MEDICAL STAFF BYLAWS AND POLICIES ATTESTATION I, FIRST_NAME LAST_NAME), attest that I have read and reviewed the medical staff bylaws and policies. Signature_____________________________________________________________________ DISASTER CALL LIST ATTESTATION I, FIRST_NAME LAST_NAME), understand that my contact information from my application will be placed on a Disaster Call List. Signature_____________________________________________________________________ Date ___________________________ Date ___________________________ Date ___________________________