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HomeMy WebLinkAboutMINUTES - 07072015 - C.36RECOMMENDATION(S): Approve the medical staff appointments and reappointments, additional privileges, primary department changes, medical staff advancement, voluntary resignations and new applicant and reappointment forms, as recommend by the Medical Staff Executive Committee, at their May 18 and June 15 meetings, and by the Health Services Director. FISCAL IMPACT: None. BACKGROUND: The Joint Commission on Accreditation of Healthcare Organizations has requested that evidence of Board of Supervisors approval for each Medical Staff member will be placed in his or her Credentials File. The above recommendations for appointment/reappointment were reviewed by the Credentials Committee and approved by the Medical Executive Committee. APPROVE OTHER RECOMMENDATION OF CNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE Action of Board On: 07/07/2015 APPROVED AS RECOMMENDED OTHER Clerks Notes: VOTE OF SUPERVISORS AYE:John Gioia, District I Supervisor Candace Andersen, District II Supervisor Mary N. Piepho, District III Supervisor Karen Mitchoff, District IV Supervisor ABSENT:Federal D. Glover, District V Supervisor Contact: Anna Roth, 370-5101 I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on the date shown. ATTESTED: July 7, 2015 David Twa, County Administrator and Clerk of the Board of Supervisors By: June McHuen, Deputy cc: T Scott, Sana Salman, N Rios C. 36 To:Board of Supervisors From:William Walker, M.D., Health Services Director Date:July 7, 2015 Contra Costa County Subject:Medical Staff Appointments and Reappointments – May and June 2015 CONSEQUENCE OF NEGATIVE ACTION: If this action is not approved, Contra Costa Regional Medical and Contra Costa Health Centers' medical staff would not be appropriately credentialed and not be in compliance with the Joint Commission on Accreditation of Healthcare Organizations. CHILDREN'S IMPACT STATEMENT: Not applicable. ATTACHMENTS May List June List Reappt Application New Application MEC Recommendations – June, 2015 Definitions: A=Active C=Courtesy Aff=Affliate P/A= Provisional Active P/C= Provisional Courtesy Page 1 A. New Medical Staff Members Brigitte Apfel, MD Psychiatry/Psychology Janika Hatcher, DDS Dental Martin Held, MD Psychiatry/Psychology Suneil Koliwad, MD Internal Medicine Flynne Lewis, MD Pediatrics Jerry Makin, DO Psychiatry/Psychology Yana Wirengard, MD Surgery B. New Staff Affiliation Deidra Francis, FNP Family Medicine C. Travis Residents Heather Dalton, MD Charles Howard, MD Jeffrey Vassali, MD D. Request for Additional Privileges Kimberly Butler, MD Family Medicine, Internal Medicine Emily Cotter, MD Hospitalist John Lee, MD Dermatology Jeana Radosevich, MD Internal Medicine Mena Ramos, MD Emergency Medicine E. Advance to Non-Provisional Hugo Altamirano, MD Anesthesia A Ashley Ballard, DO Family Medicine A Peyman Keyashian, MD Anesthesia A F. Biennial Reappointments Jamie Boudreau, MD Family Medicine A Karen Burt, MD Family Medicine Adm. Domenic Cavallaro, DDS Dental A Scott Faivre, DDS Dental A Jessica Hamilton, MD Emergency Medicine P Jaison James, MD Surgery A Eugenia Kang, MD Surgery P Lily Kao, MD Pediatrics C Kimberly Loda, MD Psychiatry/Psychology A Gordon Lum, MD Emergency Medicine C Jane McCormick, MD Internal Medicine A Louise McNitt, MD Family Medicine A David Piccinati, MD Emergency Medicine A Taiyun Roe, MD Family Medicine A Charles Scott, MD Pediatrics A Jessica Selvin, Psy.D Psychiatry/Psychology P Paul Shen, MD Family Medicine C MEC Recommendations – June, 2015 Definitions: A=Active C=Courtesy Aff=Affliate P/A= Provisional Active P/C= Provisional Courtesy Page 2 David Weiland, MD Internal Medicine C Zoraya Zuniga, MD Family Medicine A G. Biennial Renew of Privileges Lizabeth Linn, NP Family Medicine Aff. H. Teleradiology Renewal of Privileges Donald Nicell, MD Diagnostic Imaging Stanley Nyarko, MD Diagnostic Imaging I. 2nd Year Resident Reappointments Christina Gomez-Mira, MD Family Medicine Mena Ramos, MD Family Medicine Marcie Richmond, MD Family Medicine Kaitlyn Van Arsdell, MD Family Medicine J. Voluntary Resignations Ian Matsuura, OD Diagnostic Imaging “Faith” Hu-Hsin Wu, MD Pediatrics MEC Recommendations – May, 2015 Definitions: A=Active C=Courtesy Aff=Affliate P/A= Provisional Active P/C= Provisional Courtesy Page 1 A. New Medical Staff Members Baker, Megan, MD Psychiatry/Psychology Carcamo-Molina, Dayana, MD Internal Medicine Ibrahim, Fayaz, MD Psychiatry/Psychology Miller, Margaret, MD Psychiatry/Psychology Nguyen, Minh, MD Psychiatry/Psychology Quang-Dang, Ueyn-Khanh, MD Psychiatry/Psychology Stokes, Michael, DD Dental Sun, Jason, MD Internal Medicine Tran, Linda, DO Pediatrics Treyger, Leonid, MD Family Medicine Truong, Victor , DDS Dental Wong, Michelle, MD Family Medicine B. New Teleradiologist Staff Members Saadet Atay-Rosenthal, MD Diagnostic Imaging Tal Delman, MD Diagnostic Imaging Arati Khanna, MD Diagnostic Imaging C. Application for Moonlighting Privileges Kathryn Hamlin, MD Family Medicine Christine Henneberg, MD Family Medicine Kendra Johnson, MD Family Medicine Allison Newman, MD Family Medicine Jennifer Owen, MD Family Medicine John Par, MD Family Medicine Mana Pirnia, MD Family Medicine Jonathan Powell, MD Family Medicine Neal Sheran, MD Family Medicine D. 1st Year Residents – Family Medicine Victoria Chew, MD Madeline Cozad, MD Erik Gonzalez, MD Kari Kompaniez, MD Mariel Lougee, MD Tiffany Lu, MD Adelaide Magallanes, MD Ashley Ottman, MD Lauren Pallis, MD Evan Pulvers, MD Naman Shah, MD Marcella Torres, MD Ariel Wagner, MD MEC Recommendations – May, 2015 Definitions: A=Active C=Courtesy Aff=Affliate P/A= Provisional Active P/C= Provisional Courtesy Page 2 E. Travis Resident Applicant Matthew Hess, MD Jonathan Keenan, MD Randolph Kline, MD F. Request for Additional Privileges Gloria Asuncion, MD Pathology Ashley Ballard, DO Family Medicine Jo Elliff, FNP Family Medicine Alberto Hernandez, NP Family Medicine Brent Porteous, DO Family Medicine Andrea Sandler, MD Family Medicine Erin Stratta, MD Family Medicine Ian Wallace, MD Family Medicine G. Request to change Primary Department Sandra Murguia, FNP Family Medicine Obstetrics & Gynecology Michele Tomasulo, FNP Family Medicine Obstetrics & Gynecology H. Advance to Non-Provisional Alison Block, MD Family Medicine A Raja Dutta, MD Psychiatry/Psychology A Ahmed Farraq, MD Family Medicine A Nayvin Gordon, MD Family Medicine C Marcus Houston, MD Psychiatry/Psychology A Bryan Hyler, MD Psychiatry/Psychology C Mercedes Kwiatkowski, MD Psychiatry/Psychology C Denise L’Heureux, MD Psychiatry/ Psychology A Jelriza Mansouri, MD Obstetrics & GynecologyA Vincent Perez, MD Psychiatry/Psychology A Chere Sealey, FNP Family Medicine Aff Jessica Selvin, Psy.D Psychiatry/Psychology A Keith White, MD Pediatrics A Matthew Wright, MD Psychiatry/Psychology C I. Biennial Reappointments Aneela Ahmed, MD Psychiatry/Psychology A Mario Corona, MD Internal Medicine C Catherine Hoang Oanh Do, DDS Dental C Janet Goldman, MD Obstetrics & GynecologyC Neil Jayasekera, MD Emergency Medicine A Nerissa Ko, MD Internal Medicine P Rebecca Lee, MD Family Medicine A Scott Loeliger, MD Obstetrics & Gynecology A Renee Luburic, MD Psychiatry/ Psychology A H. Marc McDaniel, MD Psychiatry/Psychology A MEC Recommendations – May, 2015 Definitions: A=Active C=Courtesy Aff=Affliate P/A= Provisional Active P/C= Provisional Courtesy Page 3 Rebecca Miller, MD Emergency Medicine C Nancy Owens, MD Pediatrics A Shyni Subash, MD Family Medicine A Rinata Wagle, MD Psychiatry/Psychology A Biennial Renewal of Privileges Michele Madlock, CNM Family Medicine Michele Madlock, CNM Family Medicine J. Teleradiologist Biennial Reappointments Donald Nicell, MD Diagnostic Imaging C Stanley Nyarko, MD Diagnostic Imaging C K. 2nd Year Resident Reappointments Elizabeth Berryman, MD Christy Martinez, MD Tamara McBride, MD L. Voluntary Resignations David Dempsey, MD Emergency Medicine Suzhanna Elam, MD Psychiatry/Psychology Patricia Glatt, MD Family Medicine Beatrice St. Claire, MD Psychiatry/Psychology M. Approval of new application and reappointment application See attached 1 of 9 Last Updated 5/13/2015 Approved by Committees PENDING ! ! ! Credentialing & Privileging New Provider Application May 13, 2015 Dear Applicant, Thank you for your interest in becoming a part of Contra Costa Regional Medical Center and Health Centers staff. Before becoming a member of our medical staff you must complete our credentialing process. The credentialing process involves three-steps to evaluate a practitioner’s eligibility and competency for clinical privileging. Step 1: Applicant completes and returns application packet along with all requested documentation. Step 2: Application will be reviewed and processed by our credentialing staff to make sure all information is complete and accurate. Step 3: The complete and verified application will be presented at the monthly Credentials Committee, Medical Executive Committee, and Board of Supervisors meetings for review and approval. The credentialing process can take up to 12 weeks to verify, review, and obtain final approval. To help expedite the process, your application should be without blanks or missing documentation. Temporary privileges may be granted if all requirements are met. If anything is missing, the process will be delayed and could mean termination of your application. As stated in our bylaws, if an application is not completed within 90 days of initial receipt, the application will be returned and reapplication will be restricted for an additional period of 90 days. As part of the process you will be interviewed by a Department or Division Head. You may additionally be interviewed by a member of the Credentials Committee. After your file has been approved you will receive notice with an appointment letter from the credentialing department. If needed, please set up a meeting to go over your application prior to submission. If at any time you have questions regarding the process or your application, please feel free to contact the Medical Staff Office Credentials Department. Our goal is to assist you to get on staff as quickly as possible. **Please note that there may be additional papers for county employment purposes, membership with the Medical Staff is separate from employment with Contra Costa County. The Medical Staff Office is only concerned with your credentialing and privileging in our institution. 2 of 9 Last Updated 5/13/2015 Approved by Committees PENDING ! Application Acknowledgement: I understand that I have the burden of producing adequate information for a proper evaluation of my current competence, character, ethics, and other qualifications, as well as for resolving any doubts about such qualifications. To accomplish this, I have provided all of the information requested within this document and agree to provide all other information as may be requested for the application process. I understand that if I do not complete my application including attachment of all required supporting documents within 90 days of receipt, this request for application shall be consider void, no further processing will take place, and this request shall be deemed withdrawn with no opportunity to reapply for an additional 90 days. Initial: _______ Date: ____/____/____ Application Documentation: Please ensure that the application form is complete, including current names and full current addresses, phone and fax numbers of all schools, training facilities, hospital affiliations and references. Please also attach all required documentation. Incomplete applications will be returned to you and may result in a delay in the credentialing process. • Application Documents that must be complete and submitted include the following: _____ Completed Application (Including signed Attestation Statements and Information Release (Pgs. 8-9 in application)) _____ Signed and Dated CCRMC Release Forms _____ Completed Privilege Request Form(s) _____ Professional Liability Claims History (Addendum B) _____ Continuing Medical Education Credits (CMEs) for prior two years (written in app or certificates provided) _____ Three Peer References (Must be recent and in same specialty, at least one must have had a supervisory role) • Please also submit the following with your application: _____ Curriculum Vitae (CV) (include current practices as well as complete work history, explaining any gaps over 30 days) _____ Copy of Valid State Medical License _____ Current Drug Enforcement Administration (DEA) registration (if applicable) _____ Copy of Diploma/Certificates if within last 2 years (medical school, residency, fellowship) _____ Proof of professional liability insurance (policy declaration page or letter from insurer) _____ Copy of clear viewable government issued photo identification (Driver’s License, Passport, Military ID) _____ Completed Affidavit of Identification (must be completed by CCRMC employee or certified notary) _____ Current Board Certification (if applicable) _____ ECFMG Certification (if applicable) _____ Fluoroscopy/RHB Certification (if applicable) _____Clinical Activity Log (all clinics, admissions, and procedures from prior two years) _____Check Payable to CCRMC Medical Staff (Nonrefundable: $300.00 for physicians/$150.00 for Affiliates) 3 of 9 Last Updated 5/13/2015 Approved by Committees PENDING ! I. IDENTIFYING INFORMATION: Full Name: __________________________________________________________________________________ Last First MI Title (MD, DO, NP, etc.) Is there any other name under which you have been known? Name(s): ___________________________________ Home Mailing Address:________________________________________________________________________ City State Zip Home Phone: _______________________________ Cell Phone: ________________________________ Work Phone: _______________________________ Pager Number: _____________________________ Primary Email: _____________________________ Foreign Languages: _________________________ Date of Birth: _______/_______/_______ Place of Birth: ______________________________________ Social Security #: ___________________________________ Medicare UPIN/NPI #: _______________________________ Citizenship: ________________________________________ (If not United States citizen, please include copy of Alien Registration Card). Gender: ______ Male ______ Female Hiring Agency/Group (if applicable): _________________________________ Contact Name: ______________________________ Phone: __________________________ Fax: __________________________ Email: _____________________________________ Mailing Address:____________________________________________________________________________________________ City State Zip II. STAFF CATEGORY: Please indicate which facility and staff category you are applying for. Department(s):__________________________________ Specialty: _____________________________________ Name of Hiring Provider: ________________________ Proposed Start Date (if known): ______/______/______ Facility/Program Name Check All That Apply Staff Category Descriptions (please indicate which applies): Antioch Health Center Active Staff: These members regularly use the hospital and/or health centers for care of patients (usually more than 16 hours per week). These members are usually more active, can vote in hospital matters and pay higher reappointment dues. Bay Point Family Health Center Brentwood Health Center Concord Health Center CCRMC (County Hospital) Detention Facilities Courtesy Staff: These members occasionally use the hospital and/or health centers for care of patients (usually less than 16 hours per week). These members are less active, cannot vote, and pay slightly lower reappointment dues. Martinez Health Center Miller Wellness Center North Richmond Center for Health Pittsburg Health Center Planned Parenthood Allied Health: These members include: Nurse practitioners (NPs), Midwifes (CNMS, CPMS, & LMS), Physicians assistants (PAs) and Optometrists. Public Health West County Health Center Willow Pass Wellness Center West County Mental Health Adult or Child No/Low Volume: These providers are on active medical staff at another facility and treat most of their patients there. They provide specialty/subspecialty services at CCRMC/Health Centers in the role of consultants or experts who are specifically tasked to care for a defined subset of patients. East County Mental Health Adult or Child Central County Mental Health Adult or Child First Hope Program Wright Institute Other Facility (please list): 4 of 9 Last Updated 5/13/2015 Approved by Committees PENDING ! III. EDUCATION (Attach additional sheet if necessary): Premedical Education: Institution Name: _________________________________________________________________________ Degree Received: __________________________ Dates of Attendance: ______/_______ to _______/_______ ! Mailing Address:_________________________________________________________________________________ City State Zip Phone: ______________________________ Fax: ______________________________ Medical Education: Medical School Name: ____________________________________________________________________________ Degree Received: __________________________ Dates of Attendance: ______/_______ to _______/_______ ECFMG Number (for foreign graduates): ______________ Issue/Expiration Date: _____/_____ to _____/_____ Mailing Address:_________________________________________________________________________________ City State Zip Phone: ______________________________ Fax: ______________________________ Other Education: Other Institution Name: ___________________________________________________________________________ Degree Received: __________________________ Dates of Attendance: ______/_______ to _______/_______ Mailing Address:_________________________________________________________________________________ City State Zip Phone: ______________________________ Fax: ______________________________ IV. INTERSHIPS/RESIDENCIES/FELLOWSHIPS (Attach additional sheets if necessary). Institution Name: ________________________________________________________________________________ Program Director: ____________________________________ Dates of Completion: _____/_____ to _____/_____ Training Type: ______________________________ Specialty: _________________________________________ Mailing Address:_________________________________________________________________________________ City State Zip Phone: ______________________________ Fax: ______________________________ Did you successfully complete this program? ____ Yes _____ No (If “No” please attach explanation).! Institution Name: ________________________________________________________________________________ Program Director: ____________________________________ Dates of Completion: _____/_____ to _____/_____ Training Type: ______________________________ Specialty: _______________________________________ Mailing Address:_________________________________________________________________________________ City State Zip Phone: ______________________________ Fax: ______________________________ Did you successfully complete this program? ____ Yes _____ No (If “No” please attach explanation).! 5 of 9 Last Updated 5/13/2015 Approved by Committees PENDING ! Institution Name: ________________________________________________________________________________ Program Director: ____________________________________ Dates of Completion: _____/_____ to _____/_____ Training Type: ______________________________ Specialty: _______________________________________ Mailing Address:_________________________________________________________________________________ City State Zip Phone: ______________________________ Fax: ______________________________ Did you successfully complete this program? ____ Yes _____ No (If “No” please attach explanation).! V. BOARD CERTIFICATION (Attach additional sheets if necessary). 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 Osteopathic Association • a board or association with equivalent requirements approved by the Medical Board of California • a board or association with an 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: Specialty: Date of Original Certification: Date of Expiration/ Recertification: ____/____/____ ____/____/____ ____/____/____ ____/____/____ ____/____/____ ____/____/____ 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:_____________________ ___________________________________________________________________________________________________ I. OTHER CERTIFICATIONS (E.G. PALS, BLS, FLUOROSCOPY, RADIOGRAPHY, ETC.) (Attach additional sheets if necessary). Type: Number: Cert. date: _____/_____/_____ Exp. Date: _____/_____/_____ Type: Number: Cert. date: _____/_____/_____ Exp. Date: _____/_____/_____ Type: Number: Cert. date: _____/_____/_____ Exp. Date: _____/_____/_____ I. PROFESSIONAL LIABILITY (List all carriers within past 7 years. Attach additional sheets if necessary). Current Insurance Carrier: _____________________________________________________________________ Policy Number: _________________________ Dates of Coverage: _______/______/______ to ______/______/______ Per Claim Amount: ______________________ Aggregate Amount: ______________________ Insurance Carrier: ____________________________________________________________________________ Policy Number: _________________________ Dates of Coverage: _______/______/______ to ______/______/______ Insurance Carrier: ___________________________________________________________________________ Policy Number: _________________________ Dates of Coverage _______/______/______ to ______/______/______ 6 of 9 Last Updated 5/13/2015 Approved by Committees PENDING ! II. CURRENT AFFILIATIONS & WORK HISTORY (Attach additional sheets or CV if necessary). Please list all institutions where you have current or previous hospital privileges during the past ten years. This includes hospitals, surgery centers, corporations, military assignments, government agencies, etc. Please provide the current contact information for the institution medical staff office or personnel office. A. Current Affiliation(s) Primary Institution Name: __________________________________________________________________________ Department: _______________________________________ Staff Status: _________________________________ Dates of Affiliation: ____/____ to ____/____ Phone: _______________________ Fax: ______________________ Mailing Address:_________________________________________________________________________________ City State Zip Institution Name: ________________________________________________________________________________ Department: _______________________________________ Staff Status: _________________________________ Dates of Affiliation: ____/____ to ____/____ Phone: _______________________ Fax: ______________________ Mailing Address:_________________________________________________________________________________ City State Zip Institution Name: ________________________________________________________________________________ Department: _______________________________________ Staff Status: _________________________________ Dates of Affiliation: ____/____ to ____/____ Phone: _______________________ Fax: ______________________ Mailing Address:_________________________________________________________________________________ City State Zip B. Previous/Other Affiliation(s)/Position(s) Institution Name: ________________________________________________________________________________ Department: _______________________________________ Staff Status: _________________________________ Dates of Affiliation: ____/____ to ____/____ Phone: _______________________ Fax: ______________________ Mailing Address:_________________________________________________________________________________ City State Zip Institution Name: ________________________________________________________________________________ Dates of Affiliation: ____/____ to ____/____ Phone: _______________________ Fax: _______________________ Mailing Address:_________________________________________________________________________________ City State Zip Institution Name: ________________________________________________________________________________ Dates of Affiliation: ____/____ to ____/____ Phone: _______________________ Fax: _______________________ Mailing Address:_________________________________________________________________________________ City State Zip Institution Name: ________________________________________________________________________________ Dates of Affiliation: ____/____ to ____/____ Phone: _______________________ Fax: _______________________ Mailing Address:_________________________________________________________________________________ City State Zip 7 of 9 Last Updated 5/13/2015 Approved by Committees PENDING ! III. PEER REFERENCES List three professional references, preferably from your specialty, not including relatives, current partners or associates in practice. If possible, include at least one individual who has directly supervised your work. ** References must be from individuals who are currently directly familiar with your work and have observed such work within the past year either via clinical observation or through close working relations. Name of Reference: _________________________________________________________________________________ Last First Title Specialty: ________________________________ Time Frame Observed: ______/_____/_____ to ______/_____/_____ Mailing Address:____________________________________________________________________________________ City State Zip Phone: _______________________________ Email: _____________________________________ Name of Reference: __________________________________________________________________________________ Last First Title Specialty: ________________________________ Time Frame Observed: ______/_____/_____ to ______/_____/_____ Mailing Address:____________________________________________________________________________________ City State Zip Phone: _______________________________ Email: _____________________________________ Name of Reference: _________________________________________________________________________________ Last First Title Specialty: ________________________________ Time Frame Observed: ______/_____/_____ to ______/_____/_____ Mailing Address:____________________________________________________________________________________ City State Zip Phone: _______________________________ Email: _____________________________________ IV. CONTINUING MEDICAL EDUCATION (CMEs) Courses must relate to your practice and will be reviewed toward granting privileges. CCRMC requires 50 CMEs for medical physicians, 36 for psychiatrists, and 30 for NPs/CNMs for the prior two years or double those amounts for the prior four. Please either write courses below or attach relevant certificates. Course/Conference: Date(s): Number of Credits: 8 of 9 Last Updated 5/13/2015 Approved by Committees PENDING ! V. ATTESTATION QUESTIONS Please answer the following questions “yes” or “no.” If your answer to questions A through K is “yes” or your answer to L is “no” please attach a full description on a separate sheet of paper. A. Has your license to practice medicine, your Drug Administration (DEA) registration or any applicable narcotic registration in any jurisdiction ever been denied, limited, restricted, suspended, revoked, not renewed, or subject to probationary conditions, or have you voluntarily or involuntarily relinquished any such license or registration or voluntarily or involuntarily accepted any such actions or conditions, or have you been fined or received a letter of reprimand or is such action pending? Yes No B. Have you ever been charged, suspended, fined, disciplined, or otherwise sanctioned, subjected to probationary conditions, restricted or excluded, or have you voluntarily or involuntarily relinquished eligibility to provide service or accepted conditions on your eligibility to provide services, for reasons relating to possible incompetence or improper professional conduct, or breach of contract or program conditions by Medicare, Medicaid, or any public program, or is any such action pending? Yes No C. Have your 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), ever been denied, suspended, restricted, reduced, subjected to probationary conditions, revoked or not renewed for possible incompetence, improper professional conduct or breach of contract, or is any such action pending? Yes No D. Have you ever surrendered, allowed to expire, voluntarily or involuntarily withdrawn a request for membership or clinical privileges, terminated contractual participation or employment, or resigned from 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) while under investigation for possible incompetence or improper professional conduct, or breach of contract, or in return for such an investigation not being conducted, or is any such action pending? Yes No E. Have you ever surrendered, voluntarily withdrawn, or been requested or compelled to relinquish your status as a student in good standing in any internship, residency, fellowship, preceptorship, or other clinical education program? Yes No F. Has your membership or fellowship in any local, county, state, regional, national or international professional organization ever been revoked, denied, reduced, limited, subjected to probationary conditions, or not renewed, or is any such action pending? Yes No G. Have you been denied certification/recertification by a specialty board, or has your eligibility, certification or recertification status changed (other than changing from eligible to certified)? Yes No H. Have you ever been convicted of any crime (other than minor traffic violations)? Yes No I. Do you presently use any drugs illegally? Yes No J. Have any judgements 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 against you pending? Yes No K. 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? Yes No L. Are you able to perform all the services required by your agreement with, or the professional staff bylaws of Contra Costa Regional Medical Center and Clinics, 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 I hereby affirm that the information submitted and any addenda thereto is true, current, correct, and complete to the best of my knowledge and belief and is furnished in good faith. I understand that omissions or misrepresentations may result in denial of my application or termination of my privileges, employment, or physician participation agreement. Print Name: __________________________________ Practitioner Signature: _____________________________ Date: _____/_____/_____ (Stamped Signature Not Accepted) 9 of 9 Last Updated 5/13/2015 Approved by Committees PENDING ! INFORMATION RELEASE/ACKNOWLEDGEMENTS I hereby consent to the disclosure, inspection and copying of information and documents relating to my credentials, qualifications and performance (*credentialing information*) by and between “this Healthcare Organization” and other healthcare organizations (e.g., hospital medical staffs, medical groups, independent practice associations (IPAs), health plans, health maintenance organizations (HMOs), preferred provider organizations (PPOs), other health delivery systems or entities, medical societies, professional associations, medical school faculty positions, training programs, professional liability insurance companies (with respect to certification of coverage and claims history), licensing authorities and business and individuals acting as their agents (collectively, ‘healthcare organizations’) for the purpose of evaluating this application and any recredentialing application regarding my professional training, experience, character, conduct and judgement ethics, and ability to work with others. In this regard, the utmost care shall be taken to safeguard the privacy of patients and the confidentiality of patient records, and to protect credentialing information from being further disclosed. I am informed and acknowledge that federal and state3 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”, and all person and entities proving credentialing information to such representative 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 understand that I shall be afforded such fair procedure with respect to my participation in “this Healthcare Organization” as may be required by state and federal law and regulation, including but no limited to, California Business and Professions Code Section 809 et. seq, if applicable. I understand and agree that I, as an applicant, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics and other qualifications and for resolving any doubt about such qualifications. During such time as this application is being processed, I agree to update the application should there be any change in the information provided. In addition to any notice required by any contract with a healthcare organization, I agree to notify “this Healthcare Organization” immediately in writing of the occurrence of any of the following: (i) the unstayed suspension, revocation or nonrenewal of my license to practice medicine in California; (ii) any suspension, revocation or nonrenewal of my DEA or other controlled substances registration (iii) any cancellation or nonrenewal of my professional liability insurance coverage. I further agree to notify “this Healthcare Organization” in writing, promptly and no later than fourteen (14) days from the occurrence of any of the following: (i) recipient of written notice of any adverse action against me by the Medical Board of California taken or pending, including but not limited to, any accusation filed, temporary restraining order, or imposition of any interim suspension, probation or limitations affecting my license to practice medicine; or (ii) any adverse action against me by any Healthcare Organization which has resulted in the filing of a Section 805 report with the Medical Board of California or a report with the National Practitioner Data Bank; or (iii) the denial, revocation, suspension, reduction, limitation, nonrenewal or voluntary relinquishment by resignation of my medical staff membership or clinical privileges at any Healthcare Organization; or (iv) any material reduction in my professional liability insurance coverage or (v) my receipt of written notice of any legal action against me, including, without limitation, any filed and served malpractice suit or arbitration action; or (vi) my conviction of any crime (excluding minor traffic violations); or (vii) my receipt of written notice of any adverse action against me under the Medicare or Medicaid programs, including but not limited to, fraud and abuse proceedings or convictions. I hereby affirm that the information submitted in this application and any addenda thereto (including my curriculum vitae if attached) is true, current, correct, and complete to the best of my knowledge and belief and is furnished in good faith. I understand that material omissions or misrepresentation may result in denial of my application or termination of my privileges, employment or physician participation agreement. A photocopy of this document shall be as effective as the original, however, original signatures and current dates are required on pages 8 and 9. Print Name: __________________________________ Practitioner Signature: _____________________________ Date: _____/_____/_____ (Stamped Signature Not Accepted) _______________________________________________________________________________________________________________ 3 the intent of this release is to apply at minimum, protections comparable to those available in California to any action, regardless of where such action is brought. 1 of 2! ! CALIFORNIA PARTICIPATING PHYSICIANS ADDENDUM B PROFESSIONAL LIABILITY ACTION EXPLANATION This addendum is submitted to: Contra Costa Regional Medical Center herein, this Healthcare Organization1 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 this 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 any 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 professional liability lawsuit or arbitration action, please photocopy this form prior to completing and complete a separate form for each lawsuit. I. IDENTIFYING INFORMATION Full Name: ______________________________________________________________________________________ Last First MI Mailing Address:____________________________________________________________________________________ City State Zip II. CASE INFORMATION City, County and State Where Lawsuit Filed: ________________ _____________________________________________________ Court Case Number (if known): ____________________ Date of Alleged Incident Serving as Basis for Suit: ____/____/____ Date Suit Filed: ____/____/____ Sex of Patient: ____ Male ____ Female Age of Patient: _____________ Location of Incident: Hospital My Office Other Doctor’s Office Surgery Center Other: ____________________ Your Relationship to Patient (Attending Physician, Surgeon, Assistant, Consultant, etc.): __________________________ Allegation Description: ______________________________________________________________________________ _________________________________________________________________________________________________ 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: Insurer Name: ______________________________________ Contact Name: ________________________ Phone: __________________________ Fax: __________________________ Claim ID ________________________ Mailing Address:_________________________________________________________________________________ City State Zip If you would like us to contact your attorney regarding any of the above, please provide name(s) and phone number(s). Please fax this document to your attorney as this will serve as your authorization. Attorney Name: ______________________________________ Phone Number: ________________________ Attorney Name: ______________________________________ Phone Number: ________________________ 1As used in the Information Release section of this Addendum, the term “this Healthcare Organization” shall refer to the entity to which this Addendum is submitted as identified above. CHECK HERE IF NONE: 2 of 2! ! III. LAWSUIT/ARBITRATION STATUS Lawsuit/Arbitration still ongoing, unresolved Judgement rendered and payment was made on my behalf Amount paid on my behalf $________________ Judgement rendered and I was found not liable Lawsuit/Arbitration settles and payment made on my behalf Amount paid on my behalf $________________ Lawsuit/Arbitration settled, no judgement rendered, and no payment on my behalf Please provide a legible summary 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). Please include: 1. Condition and diagnosis at time of incident 2. Dates and description of treatment rendered, and 3. Condition of patient before treatment. 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, which is part of the application. In order for participating healthcare organizations to evaluate my application or participation in and/or my continued participation in those organizations, I hereby give permission to release to “this Healthcare Organization” information about my medical malpractice insurance coverage and claims history. This authorization is expressly contingent upon 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 and until it is revoked by me in writing. I authorize the attorney(s) listed on page 1 of this document to discuss any information regarding this case with “this Healthcare Organization.” Print Name: __________________________________ Practitioner Signature: _____________________________ Date: _____/_____/_____ (Stamped Signature Not Accepted) 1 of 6 Last Updated 5/13/2015 Approved by Committees PENDING ! ! ! Credentialing & Privileging Reappointment Application May 13, 2015 Dear Provider, Thank you for being a part of Contra Costa Regional Medical Center and Health Centers staff. Every two years providers must be reappointed to the medical staff. Applications are sent out six months prior to your birth month and are to be completed and returned to the Medical Staff Office within 45 days. The reappointment process involves three-steps to evaluate a practitioner’s continued eligibility and competency for clinical privileging. Step 1: Applicant completes and returns application packet along with all requested documentation. Step 2: Application will be reviewed and processed by our credentialing staff to make sure all information is complete and accurate. Step 3: The complete and verified application will be presented at the monthly Credentials Committee, Medical Executive Committee, and Board of Supervisors meetings for review and approval. The recredentialing process can take up to 12 weeks to verify, review, and obtain final approval. To help expedite the process, your application should be without blanks or missing documentation. If anything is missing, the process will be delayed and could mean assessment of accruing late fees or termination of your privileges. Application Documentation: Please ensure that the application form is complete, including names and full current addresses, phone and fax numbers of all schools, training facilities, hospital affiliations and references. Please also attach all required documentation. Incomplete applications will be returned to you and may result in a delay in the credentialing process. • Application Documents that must be complete and submitted include the following: _____ Completed Application (Including signed Attestation Statements and Information Release (Pgs. 5-6 in application)) _____ Signed and Dated CCRMC Release Forms _____ Completed Privilege Request Packet _____ Professional Liability Claims History (Addendum B) _____ Continuing Medical Education Credits (CMEs) for prior two years (written in app or certificates provided) • Please also submit the following with your application: _____ Updated Curriculum Vitae (CV) (If Applicable) _____ Copy of Valid State Medical License _____ Current Drug Enforcement Administration (DEA) registration (if applicable) _____ Copy of any Diploma/Certificates if within last 2 years (medical school, residency, fellowship, etc.) _____ Proof of professional liability insurance (if not insured by the county policy) _____Clinical Activity Log (No/Low Volume Providers Only: all clinics, admissions, and procedures from prior two years) _____Check Payable to CCRMC Medical Staff (Nonrefundable: $200.00 for Active/$100.00 for Courtesy/Affiliate) 2 of 6 Last Updated 5/13/2015 Approved by Committees PENDING ! I. IDENTIFYING INFORMATION: Full Name: _______________________________________________________________________________________ Last First MI Title (MD, DO, NP, etc.) Is there any other name under which you have been known? Name(s): ________________________________________ Home Mailing Address:_____________________________________________________________________________ City State Zip Home Phone: _________________________________ Cell Phone: __________________________________ Work Phone: _________________________________ Pager Number: _________________________________ Primary Email: _________________________________ Work Email: ___________________________________ Hiring Agency/Private Practice/Locums/etc. (if applicable): _________________________________________________ Contact Name: ____________________________________ Email: _________________________________________ Contact Phone: ____________________________________ Fax: __________________________________________ Mailing Address: ___________________________________________________________________________________ City State Zip II. STAFF CATEGORY: Please indicate which facility and staff category you are applying for. Please indicate in which department(s) and at what location(s) you are currently working: Department(s): ____________________________________ Specialty: _______________________________________ Facility/Program Name Check All That Apply Staff Category Descriptions (please indicate which applies): Antioch Health Center Active Staff: These members regularly use the hospital and/or health centers for care of patients (usually more than 16 hours per week). These members are usually more active, can vote in hospital matters and pay higher reappointment dues. Courtesy Staff: These members occasionally use the hospital and/or health centers for care of patients (usually less than 16 hours per week). These members are less active, cannot vote, and pay slightly lower reappointment dues. Allied Health: These members include: Nurse practitioners (NPs), Midwifes (CNMS, CPMS, & LMS), Physicians assistants (PAs) and Optometrists. No/Low Volume: These providers are on active medical staff at another facility and treat most of their patients there. They provide specialty/subspecialty services at CCRMC/Health Centers in the role of consultants or experts who are specifically tasked to care for a defined subset of patients. Bay Point Family Health Center Brentwood Health Center Concord Health Center CCRMC (County Hospital) Detention Facilities Martinez Health Center Miller Wellness Center North Richmond Center for Health Pittsburg Health Center Planned Parenthood Public Health West County Health Center Willow Pass Wellness Center West County Mental Health East County Mental Health Central County Mental Health First Hope Program Wright Institute Other Facility (please list): 3 of 6 Last Updated 5/13/2015 Approved by Committees PENDING ! III. BOARD CERTIFICATION (Attach additional sheets if necessary). Check here if nothing has changed: Include certifications by board(s) which are duly organized and recognized by: • a member board of the American Board of Medical Specialties or American Osteopathic Association • a board or association with equivalent requirements approved by the Medical Board of California • a board or association with an 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: Specialty: Date of Original Certification: Date of Expiration/Recertification: 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:____________________________ __________________________________________________________________________________________________________ IV. OTHER CERTIFICATIONS (E.G. PALS, BLS, FLUOROSCOPY, RADIOGRAPHY, ETC.) (Attach additional sheets if necessary). Type: Number: Certification date: _____/_____/_____ Exp. Date: ____/_____/_____ Type: Number: Certification date: ____/_____/_____ Exp. Date: ____/_____/_____ V. PROFESSIONAL LIABILITY (List all carriers within past 2 years. Attach additional sheets if necessary). Current Insurance Carrier: _________________________________________________________________ Policy Number: ______________________________ Dates of Coverage: ______/______ to ______/______ Per Claim Amount: ___________________ Aggregate Amount: ___________________ Insurance Carrier: _______________________________________________________________________ Policy Number: ______________________________ Dates of Coverage: ______/______ to ______/______ Insurance Carrier: _______________________________________________________________________ Policy Number: ______________________________ Dates of Coverage: ______/______ to ______/______ VI. CONTINUING MEDICAL EDUCATION (CMEs) Courses must relate to your practice and will be reviewed toward granting privileges. CCRMC requires 50 CMEs for medical physicians, 36 for psychiatrists, and 30 for NPs/CNMs for the prior two years or double those amounts for the prior four. Please either write courses below or attach relevant certificates. Course/Conference: Date: Number of Credits: 4 of 6 Last Updated 5/13/2015 Approved by Committees PENDING ! VII. PEER REFERENCE (For No/Low Volume Providers) If you qualify as a no /low volume provider (see description on page 2) please provide one peer reference, preferably from your specialty, not including relatives, current partners or associates in practice. ** References must be from individuals who are currently directly familiar with your work and have observed such work within the past year either via clinical observation or through close working relations. Name of Reference: _________________________________________________________________________________________ Last First Title Specialty: _____________________________________ Time Frame Observed: _______/_______ to _______/_______ Home Mailing Address: ______________________________________________________________________________________ City State Zip Phone: ________________________________________ Email: _____________________________________________ VIII. CURRENT AFFILIATIONS & WORK HISTORY (Attach additional sheets or CV if necessary). Please list all institutions where you have had hospital privileges during the past two years. This includes hospitals, surgery centers, corporations, military assignments, government agencies, etc. Please provide the current contact information for the institution medical staff office or personnel office. A. Current Affiliation(s) Primary Institution Name: ____________________________________________________________________________________ Department: _______________________________________ Staff Status: ___________________________________________ Dates of Affiliation: _____/_____ to _____/_____ Phone: _________________________ Fax: __________________________ Mailing Address:___________________________________________________________________________________________ City State Zip Institution Name: ___________________________________________________________________________________________ Department: _______________________________________ Staff Status: ___________________________________________ Dates of Affiliation: _____/_____ to _____/_____ Phone: _________________________ Fax: __________________________ Mailing Address:___________________________________________________________________________________________ City State Zip Institution Name: ___________________________________________________________________________________________ Department: _______________________________________ Staff Status: ___________________________________________ Dates of Affiliation: _____/_____ to _____/_____ Phone: _________________________ Fax: __________________________ Mailing Address:___________________________________________________________________________________________ City State Zip B. Previous/Other Affiliation(s)/Position(s) Institution Name: __________________________________________________________________________________________ Dates of Affiliation: _____/_____ to _____/_____ Phone: _________________________ Fax: __________________________ Mailing Address:___________________________________________________________________________________________ City State Zip Institution Name: __________________________________________________________________________________________ Dates of Affiliation: _____/_____ to _____/_____ Phone: _________________________ Fax: __________________________ Mailing Address:___________________________________________________________________________________________ City State Zip Institution Name: __________________________________________________________________________________________ Dates of Affiliation: _____/_____ to _____/_____ Phone: _________________________ Fax: __________________________ Mailing Address:___________________________________________________________________________________________ City State Zip 5 of 6 Last Updated 5/13/2015 Approved by Committees PENDING ! I. ATTESTATION QUESTIONS Please answer the following questions “yes” or “no.” If your answer to questions A through K is “yes” or your answer to L is “no” please attach a full description on a separate sheet of paper. A. Has your license to practice medicine, your Drug Administration (DEA) registration or any applicable narcotic registration in any jurisdiction ever been denied, limited, restricted, suspended, revoked, not renewed, or subject to probationary conditions, or have you voluntarily or involuntarily relinquished any such license or registration or voluntarily or involuntarily accepted any such actions or conditions, or have you been fined or received a letter of reprimand or is such action pending? Yes No B. Have you ever been charged, suspended, fined, disciplined, or otherwise sanctioned, subjected to probationary conditions, restricted or excluded, or have you voluntarily or involuntarily relinquished eligibility to provide service or accepted conditions on your eligibility to provide services, for reasons relating to possible incompetence or improper professional conduct, or breach of contract or program conditions by Medicare, Medicaid, or any public program, or is any such action pending? Yes No C. Have your 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), ever been denied, suspended, restricted, reduced, subjected to probationary conditions, revoked or not renewed for possible incompetence, improper professional conduct or breach of contract, or is any such action pending? Yes No D. Have you ever surrendered, allowed to expire, voluntarily or involuntarily withdrawn a request for membership or clinical privileges, terminated contractual participation or employment, or resigned from 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) while under investigation for possible incompetence or improper professional conduct, or breach of contract, or in return for such an investigation not being conducted, or is any such action pending? Yes No E. Have you ever surrendered, voluntarily withdrawn, or been requested or compelled to relinquish your status as a student in good standing in any internship, residency, fellowship, preceptorship, or other clinical education program? Yes No F. Has your membership or fellowship in any local, county, state, regional, national or international professional organization ever been revoked, denied, reduced, limited, subjected to probationary conditions, or not renewed, or is any such action pending? Yes No G. Have you been denied certification/recertification by a specialty board, or has your eligibility, certification or recertification status changed (other than changing from eligible to certified)? Yes No H. Have you ever been convicted of any crime (other than minor traffic violations)? Yes No I. Do you presently use any drugs illegally? Yes No J. Have any judgements 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 against you pending? Yes No K. 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? Yes No L. Are you able to perform all the services required by your agreement with, or the professional staff bylaws of Contra Costa Regional Medical Center and Clinics, 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 I hereby affirm that the information submitted and any addenda thereto is true, current, correct, and complete to the best of my knowledge and belief and is furnished in good faith. I understand that omissions or misrepresentations may result in denial of my application or termination of my privileges, employment, or physician participation agreement. Print Name: __________________________________ Practitioner Signature: _____________________________ Date: _____/_____/_____ (Stamped Signature Not Accepted) 6 of 6 Last Updated 5/13/2015 Approved by Committees PENDING ! INFORMATION RELEASE/ACKNOWLEDGEMENTS I hereby consent to the disclosure, inspection and copying of information and documents relating to my credentials, qualifications and performance (*credentialing information*) by and between “this Healthcare Organization” and other healthcare organizations (e.g., hospital medical staffs, medical groups, independent practice associations (IPAs), health plans, health maintenance organizations (HMOs), preferred provider organizations (PPOs), other health delivery systems or entities, medical societies, professional associations, medical school faculty positions, training programs, professional liability insurance companies (with respect to certification of coverage and claims history), licensing authorities and business and individuals acting as their agents (collectively, ‘healthcare organizations’) for the purpose of evaluating this application and any recredentialing application regarding my professional training, experience, character, conduct and judgement ethics, and ability to work with others. In this regard, the utmost care shall be taken to safeguard the privacy of patients and the confidentiality of patient records, and to protect credentialing information from being further disclosed. I am informed and acknowledge that federal and state3 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”, and all person and entities proving credentialing information to such representative 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 understand that I shall be afforded such fair procedure with respect to my participation in “this Healthcare Organization” as may be required by state and federal law and regulation, including but no limited to, California Business and Professions Code Section 809 et. seq, if applicable. I understand and agree that I, as an applicant, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics and other qualifications and for resolving any doubt about such qualifications. During such time as this application is being processed, I agree to update the application should there be any change in the information provided. In addition to any notice required by any contract with a healthcare organization, I agree to notify “this Healthcare Organization” immediately in writing of the occurrence of any of the following: (i) the unstayed suspension, revocation or nonrenewal of my license to practice medicine in California; (ii) any suspension, revocation or nonrenewal of my DEA or other controlled substances registration (iii) any cancellation or nonrenewal of my professional liability insurance coverage. I further agree to notify “this Healthcare Organization” in writing, promptly and no later than fourteen (14) days from the occurrence of any of the following: (i) recipient of written notice of any adverse action against me by the Medical Board of California taken or pending, including but not limited to, any accusation filed, temporary restraining order, or imposition of any interim suspension, probation or limitations affecting my license to practice medicine; or (ii) any adverse action against me by any Healthcare Organization which has resulted in the filing of a Section 805 report with the Medical Board of California or a report with the National Practitioner Data Bank; or (iii) the denial, revocation, suspension, reduction, limitation, nonrenewal or voluntary relinquishment by resignation of my medical staff membership or clinical privileges at any Healthcare Organization; or (iv) any material reduction in my professional liability insurance coverage or (v) my receipt of written notice of any legal action against me, including, without limitation, any filed and served malpractice suit or arbitration action; or (vi) my conviction of any crime (excluding minor traffic violations); or (vii) my receipt of written notice of any adverse action against me under the Medicare or Medicaid programs, including but not limited to, fraud and abuse proceedings or convictions. I hereby affirm that the information submitted in this application and any addenda thereto (including my curriculum vitae if attached) is true, current, correct, and complete to the best of my knowledge and belief and is furnished in good faith. I understand that material omissions or misrepresentation may result in denial of my application or termination of my privileges, employment or physician participation agreement. A photocopy of this document shall be as effective as the original, however, original signatures and current dates are required on pages 8 and 9. Print Name: __________________________________ Practitioner Signature: _____________________________ Date: _____/_____/_____ (Stamped Signature Not Accepted) _______________________________________________________________________________________________________________ 3 the intent of this release is to apply at minimum, protections comparable to those available in California to any action, regardless of where such action is brought. 1 of 2! ! CALIFORNIA PARTICIPATING PHYSICIANS ADDENDUM B PROFESSIONAL LIABILITY ACTION EXPLANATION This addendum is submitted to: Contra Costa Regional Medical Center herein, this Healthcare Organization1 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 this 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 any 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 professional liability lawsuit or arbitration action, please photocopy this form prior to completing and complete a separate form for each lawsuit. I. IDENTIFYING INFORMATION Full Name: ______________________________________________________________________________________ Last First MI Mailing Address:____________________________________________________________________________________ City State Zip II. CASE INFORMATION City, County and State Where Lawsuit Filed: ________________ _____________________________________________________ Court Case Number (if known): ____________________ Date of Alleged Incident Serving as Basis for Suit: ____/____/____ Date Suit Filed: ____/____/____ Sex of Patient: ____ Male ____ Female Age of Patient: _____________ Location of Incident: Hospital My Office Other Doctor’s Office Surgery Center Other: ____________________ Your Relationship to Patient (Attending Physician, Surgeon, Assistant, Consultant, etc.): __________________________ Allegation Description: ______________________________________________________________________________ _________________________________________________________________________________________________ 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: Insurer Name: ______________________________________ Contact Name: ________________________ Phone: __________________________ Fax: __________________________ Claim ID ________________________ Mailing Address:_________________________________________________________________________________ City State Zip If you would like us to contact your attorney regarding any of the above, please provide name(s) and phone number(s). Please fax this document to your attorney as this will serve as your authorization. Attorney Name: ______________________________________ Phone Number: ________________________ Attorney Name: ______________________________________ Phone Number: ________________________ 1As used in the Information Release section of this Addendum, the term “this Healthcare Organization” shall refer to the entity to which this Addendum is submitted as identified above. CHECK HERE IF NONE: 2 of 2! ! III. LAWSUIT/ARBITRATION STATUS Lawsuit/Arbitration still ongoing, unresolved Judgement rendered and payment was made on my behalf Amount paid on my behalf $________________ Judgement rendered and I was found not liable Lawsuit/Arbitration settles and payment made on my behalf Amount paid on my behalf $________________ Lawsuit/Arbitration settled, no judgement rendered, and no payment on my behalf Please provide a legible summary 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). Please include: 1. Condition and diagnosis at time of incident 2. Dates and description of treatment rendered, and 3. Condition of patient before treatment. 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, which is part of the application. In order for participating healthcare organizations to evaluate my application or participation in and/or my continued participation in those organizations, I hereby give permission to release to “this Healthcare Organization” information about my medical malpractice insurance coverage and claims history. This authorization is expressly contingent upon 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 and until it is revoked by me in writing. I authorize the attorney(s) listed on page 1 of this document to discuss any information regarding this case with “this Healthcare Organization.” Print Name: __________________________________ Practitioner Signature: _____________________________ Date: _____/_____/_____ (Stamped Signature Not Accepted)