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Dear Applicant: Thank you for your interest in joining the Medical/Allied Staff at one of the Kettering Health Network facilities. Kettering Health Network utilizes a Central Credentialing Office in order to complete the primary source verification process. Please take time to thoroughly review your application, making sure to complete all relevant information fields, including dates, names, complete mailing addresses, email addresses and telephone/fax numbers. This will help to ensure that your application is processed in a timely manner. Please note that your references should have recent experience in observing and working with you and should be able to provide adequate information pertaining to your present professional competence and character. The Central Credentialing Office personnel will forward a “Confidential Practitioner Evaluation Form” to each of your references, as well as to the appropriate program directors, department chiefs, medical directors and other associates with whom you may have practiced.

A checklist of required enclosures is attached to this letter. Once your application is received by the Central Credentialing Office it will be reviewed for completeness. Should your application be deemed incomplete (unanswered questions or omissions, including signatures, on the application or if any of the required documentation is not submitted) the central credentialing office personnel will notify you of the incomplete application and outstanding information. Your application will also be deemed incomplete if the need arises for new, additional or clarifying information at any time during the application process. Accreditation standards require that we verify certain data with the primary source. This is accomplished by requesting verification directly from the individual or institution and requiring that their response be returned directly to our office. Information requiring primary source verification includes, but is not limited to, professional school graduation, postgraduate training, professional references, hospital affiliations, malpractice history and professional licenses. In addition, we query the National Practitioner Data Bank and the Office of Inspector General’s List of Excluded Individuals as part of consideration of any applicant. In order for your application to be considered complete, all information must be verified. Please remember that it is the applicant's ultimate responsibility to ensure that all information has been received. Upon completion of the primary source verification, your application with all related verification and supporting documentation will be sent to each applicable facility. The facility will then complete the privileging and decision making

portion of the application process and notify you of the Board’s decision. Completion of the application DOES NOT guarantee acceptance by any of our facilities.

Expedited Process - The Hospitals are pleased to offer an expedited credentialing process. The fee for this process is

an additional $250.00 to the current application fee. Upon receipt of your completed application (which includes, names, addresses, phone and fax numbers), the verification process will be implemented within one (1) business day (24 hours). Your involvement in this process is imperative as it is the applicant’s ultimate responsibility to ensure that all information

has been received (see checklist). We anticipate that this process will take approximately 21 to 30 days.

If you have any additional questions, please contact your assigned representative at 937-762-1300. Sincerely, Mandy Addison, CPCS, MSOW-C Manager, Central Credentialing Network

1 Prestige Place, Ste 550 Miamisburg, OH 45342

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APPLICANT CHECKLIST

Application processing fee: one hospital = $200 four hospitals = $650 two hospitals = $350 five hospitals = $800

three hospitals = $500 six hospitals = $950 Note: if currently on staff at an existing network facility, the fee to add an additional facility is $150.00.

Please enclose the following: Application fee (non-refundable – payable to Kettering Health Network)

If requesting the expedited process, please include an additional $250.00 (non-refundable)

Copy of your driver’s license

Recent professional “quality” color photo - driver’s license NOT acceptable – proof of identification is required either upon attending orientation or obtaining Hospital identification badge)

If not U.S. citizen, provide documentation of VISA status and/or employment authorization, including ECFMG

certification

Listing of all medical and/or other professional licenses and DEA or controlled substance certificates (active and inactive)

Verification of professional liability insurance. Certificate of Insurance and Declaration Page required. Include

past copies of your Certificate of Insurance for the past five years.

Print privilege profile(s) for each facility requested. Include clinical criteria through demonstrated

competency, i.e. case/procedure logs/patient encounters, per the privilege form.

If requesting fluoroscopic procedures, must complete the required fluoroscopy competency.

If requesting moderate sedation please complete the competency test (accessible via website) and provide a current copy of your ACLS, ATLS, PhyAmerica, documentation of approval for procedural sedation privileges from a local GDAHA hospital, or airway management course.

Curriculum Vitae with dates including month and year; include time gap explainations.

Documentation of CME – If applying at Grandview/Southview send 60 Cat 1A and 40 Category 1B or 2B (Adv Practice Professional should send 40). Other facilities, please send 10 or more reflective of current specialty.

Written plan of utilization – n/a if Kettering Physician Network employed

TB Assessment – included in application

Safety Education – included in application

Medicare/Champus Attestation Form– included in application

Medical Malpractice Insurance Agreement Form– included in application

Emergency Department Preference Form– included in application

Statement of Authorization and Release from Liability– included in application

Practitioner Disclosure and Authorization– included in application

Electronic Medical Record information (Required Test Out or Training for EPIC) – included in application

Network Orientation video. Please view via the link on website and submit the required attestation at end.

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Please type or legibly print in BLACK ink Fill in all sections - incomplete applications will not be processed.

If more space is needed, attached additional sheets and reference the section or question being answered.

Name: Date:

Please select the following facilities, staff status and clinical services/departments below for which you are applying:

Fort Hamilton Hospital

Active Courtesy Honorary Active Associate Consulting Locum Tenens

Anesthesia Emergency Medicine Ob/Gyn/Pediatrics/Neonatology

Diagnostic Radiology Medicine Psychiatry/Psychology Surgery Urgent Care

Clinical Specialty/Subspecialty : ____________________________________________

Allied Health Active Allied Health Associate Certified Nurse Midwife Licensed Nurse Practitioner

Certified Nurse Practitioner Physician Assistant Certified Nurse Specialist Registered Nurse Certified Registered Nurse Anesthetist

Greene Memorial Hospital

Active* Associate/membership only Courtesy Affiliate Associate/clinical privileges only Clinical Privileges Only

Anesthesia Emergency Medicine Ob/Gyn Pathology

Cardiology Internal Medicine Orthopedics Surgery Diagnostic Radiology Primary Care Urgent Care (includes Family Medicine)

Clinical Specialty/Subspecialty : ____________________________________________ *those applicants who receive Active staff appointment at Greene or Soin, per the Medical Staff Bylaws, will be automatically granted affiliate appointment without privileges at the other Hospital.

Allied Health Active Allied Health Associate Apheresis Technician Certified Registered Nurse Anesthetist RN (Psych) Biliary Drainage Technician Nurse Medical Assistant Surgical Assistant Certified Nurse Midwife Physician Assistant

Certified Nurse Practitioner Private OR Technician

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Grandview Medical Center (includes Southview Medical Center)

Active Active Affiliate Consulting Associate Active Courtesy

Anesthesia Family Medicine Ob/Gyn Pediatrics

Diagnostic Radiology Internal Medicine Pathology Surgery Emergency Medicine Neurology, Psychiatry and PM&R

Clinical Specialty/Subspecialty : ____________________________________________

Allied Health Active Allied Health Associate

Apheresis Technician Hospital Admin. Assist. Radiology Assistant Certified Nurse Midwife Limited Specialty Scrub Reg. Nurse First Asst (RNFA) Certified Nurse Practitioner Neonatal Nurse Practitioner Speech Pathology/Audiologist

Certified Registered Nurse Anesthetist Pump Perfusion Surgical Assistant Clinical Nurse Specialist Physician Pathology Scribe Certified Medical Asst. Nurse/ Medical Asst.

Kettering Medical Center

Active* Associate/membership only Courtesy Associate/clinical privileges only

Anesthesia Emergency Medicine Ob/Gyn Pediatrics

Cardiology Family Medicine Orthopedics Surgery Diagnostic Radiology Internal Medicine Pathology

Clinical Specialty/Subspecialty : ____________________________________________

*those applicants who receive Active staff appointment at Kettering or Sycamore, per the Medical Staff Bylaws, will be automatically granted affiliate appointment without privileges at the other Hospital.

Allied Health Active Allied Health Associate Advanced Nurse Practitioner CNS – Behavioral Health Physician Assistant Audiologist Nurse Medical Assistant Pump Perfusion Certified Registered Nurse Anesthetist Nurse Midwife Surgical Asst (non 1st)

Clinical Nurse Specialist (CNS) Pathology Assistant Surgical Asst (1st assist)

Soin Medical Center

Active Associate/membership only Courtesy Associate/clinical privileges only Clinical Privileges Only

Anesthesia Emergency Medicine Ob/Gyn Pathology

Cardiology Internal Medicine Orthopedics Surgery Diagnostic Radiology Primary Care (includes Family Medicine & Pediatrics)

Clinical Specialty/Subspecialty : ____________________________________________

*those applicants who receive Active staff appointment at Soin or Greene, per the Medical Staff Bylaws, will be automatically granted affiliate appointment without privileges at the other Hospital.

Allied Health Active Allied Health Associate

Advanced Nurse Practitioner Clinical Nurse Specialist (CNS) Physician Assistant Audiologist Nurse Medical Assistant Surgical Asst (1st assist) Certified Registered Nurse Anesthetist Pathology Assistant Surgical Asst (non 1st)

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Sycamore Medical Center (includes Kettering Behavioral Medical Center)

Active* Associate/membership only Courtesy Associate/clinical privileges only

Anesthesia Emergency Medicine Ob/Gyn Pediatrics

Cardiology Family Medicine Orthopedics Surgery Diagnostic Radiology Internal Medicine Pathology

Clinical Specialty/Subspecialty : ____________________________________________

*those applicants who receive Active staff appointment at Kettering or Sycamore, per the Medical Staff Bylaws, will be automatically granted affiliate appointment without privileges at the other Hospital.

Allied Health Active Allied Health Associate Advanced Nurse Practitioner CNS – Behavioral Health Physician Assistant Audiologist Nurse Medical Assistant Pump Perfusion Certified Registered Nurse Anesthetist Nurse Midwife Surgical Asst (non 1st)

Clinical Nurse Specialist (CNS) Pathology Assistant Surgical Asst (1st assist)

Please denote which facility will be your PRIMARY facility:

Fort Hamilton Hospital Kettering Medical Center Greene Memorial Hospital Soin Medical Center Grandview/Southview Medical Center Sycamore Medical Center

one hospital = $200 four hospitals = $650 two hospitals = $350 five hospitals = $800

three hospitals = $500 six hospitals = $950 *additional fee to expedite

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SECTION I

PERSONAL INFORMATION

Name (Last, First, Middle) Degree

Home Address/Street

City/State/Zip

Home Phone Number Cellular Phone Number

Other Name(s) used:

Marital Status Spouse Name

Date of Birth Sex: Male Female

Place of Birth: (City, State & Country)

Languages Spoken

Citizenship If not an American citizen, Status & Visa Number

SSN # Email Address

Beeper # Digital: Yes No Answering Service #

Preferred Mailing address Primary Office Home

SECTION II

LICENSURE/CERTIFICATIONS/REGISTRATIONS

For all the questions in this section, if you do not have a number but have applied, please indicate “in process.”

Ohio License Number

Expiration Date

Other State License Number/State of License (list all past and current)

Expiration Date

Expiration Date

Expiration Date

Federal DEA Number Expiration Date

NPI

CAQH Number: ____

State Narcotics Registration # or CDS Certification/State of Registration (if applicable)

Expiration Date

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CPR Certifications:

Are you certified in CPR? Yes (attach copy of certificate(s)) No Expiration Date

Check classification(s): Basic Life Support (BLS) No Expiration Date

Advanced Cardiac Life Support (ACLS) No Expiration Date

Advanced Trauma Life Support (ATLS) No Expiration Date

Neonatal Resuscitation Program (NRP) No Expiration Date

Pediatric Advanced Life Support (PALS) No Expiration Date

Pediatric Emergency Medicine Course

(APLS) No Expiration Date

Other professional certifications or credentials (please include description)

SECTION III

OFFICE/PRACTICE INFORMATION Please include all offices/practices. Copy and complete this sheet for each additional office.

Is this your primary office? Yes No

Type of Practice: Solo Single Specialty Group

Multi-specialty Group/Other Hospital Based

Please list other members of your practice and their specialties.

Please list the coverage arrangements/designated alternate. ___________________________________________

Start date with practice:

Group/Corp Name as on W9

Office Group Name/Address/Street

City/State/Zip

Office Phone After-hours number

Office Fax Office e-mail address

Results Routing Fax

Staff Person responsible for credentialing

Phone Fax E-mail

Office Manager

Phone Fax E-mail

Billing Name /Address/Street

City/State/Zip

Billing Phone _____________________________________ Billing Fax

Tax ID _______________________________________ Group NPI

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SECTION IV

PROFESSIONAL / MEDICAL EDUCATION & TRAINING/WORK HISTORY Provide history (since medical school) of all work, education and training including but not limited to medical military services, public health or business training. Provide an explanation for any gaps of more than two months.

MEDICAL EDUCATION:

University

Address/Street

City/State/Zip Degree

Telephone Number Month/Year Started Month/Year Completed

Fax Number

University

Address/Street

City/State/Zip Degree

Telephone Number Month/Year Started Month/Year Completed

Fax Number

INTERNSHIP

Facility

Address/Street

City/State/Zip Type

Phone Number Month/Year Started Month/Year Completed

Fax Number Email

Name of Internship Program Director

Was this program successfully completed? Yes No

RESIDENCIES

Facility

Program Name

Address/Street

City/State/Zip Specialty

Phone Number Month/Year Started Month/Year Completed

Fax Number Email

Name of Residency Program Director

Was this program successfully completed? Yes No

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Facility

Program Name

Address/Street

City/State/Zip Specialty

Phone Number Month/Year Started Month/Year Completed

Fax Number Email

Name of Residency Program Director

Was this program successfully completed? Yes No

FELLOWSHIPS

Facility

Program Name

Address/Street

City/State/Zip Specialty

Phone Number Month/Year Started Month/Year Completed

Fax Number Email

Name of Fellowship Program Director

Was this program successfully completed? Yes No

Facility

Program Name

Address/Street

City/State/Zip Specialty

Phone Number Month/Year Started Month/Year Completed

Fax Number Email

Name of Fellowship Program Director

Was this program successfully completed? Yes No

Other Graduate Level Education for which a degree was obtained

Degree(s) obtained

Institution

Address/Street

City/State/Zip

Telephone Number Fax Number

Dates (from/to) Email

Program Director

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International Medical Graduates

Are you certified by the Educational Council for Foreign Medical Graduates? Yes No

ECFMG #

Date Issued

ADDITIONAL QUALIFICATIONS/TRAINING

List below in chronological order, any and all additional training and places of practice, including medical military services, subspecialty training programs, or public health or business training. If more space is needed, please include an attachment. Include the following information: Dates of the training (from/to), program/training name, location (address), telephone number, contact person, and relevant comments

WORK HISTORY

Practice/Employer

Contact Name

Address/Street

City/State/Zip

Phone Fax

Dates of employment Month/Year Started Month/Year Ended

Reason for leaving

Practice/Employer

Contact Name

Address/Street

City/State/Zip

Phone Fax

Dates of employment Month/Year Started Month/Year Ended

Reason for leaving

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Practice/Employer

Contact Name

Address/Street

City/State/Zip

Phone Fax

Dates of employment Month/Year Started Month/Year Ended

Reason for leaving

SECTION V

PROFESSIONAL / MEDICAL SPECIALTY INFORMATION

For each specialty below, please indicate if you are qualified or board certified:

PRIMARY SPECIALTY

Qualified/ Eligible Certified

Not certified

No board available

Certifying Board Date

Is certification current? Yes No

Dates of current certification From (month/year) To (month/year)

Have you been recertified? Yes No Date

If status is qualified, give date status expires. Date

If qualified, date exam scheduled. Date

Board certification results pending? Yes No

SECONDARY SPECIALTY (Secondary area of practice)

Qualified/Eligible

Certified Not certified

No board available

Certifying Board Date of initial

certification

Is certification current? Yes No

Dates of current certification From (month/year) To (month/year)

Have you been recertified? Yes No Date

If status is qualified, give date status expires. Date

If qualified, date exam scheduled. Date

Board certification results pending? Yes No

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If you have applied to a specialty board for examination, give the name of the board and the date of application.

Board Date

Board Date

Board Date

SECTION VI

HEALTH CARE AFFILIATIONS

List all health care facilities at which you have ever held privileges. (Copy this page for additional facilities.)

PRIMARY FACILITY

Dept. Chairman

Date affiliation started Date affiliation ended (if applicable)

Address/Street

City/State/Zip

Phone Fax Email

Staff Status Any past or present restriction of privileges?

Yes No

(If Yes, explain. Attach additional pages if necessary.)

SECONDARY FACILITY

Dept. Chairman

Date affiliation started Date affiliation ended (if applicable)

Address/Street

City/State/Zip

Phone Fax Email

Staff Status Any past or present restriction of privileges?

Yes No

(If Yes, explain. Attach additional pages if necessary.)

SECONDARY FACILITY

Dept. Chairman

Date affiliation started Date affiliation ended (if applicable)

Address/Street

City/State/Zip

Phone Fax Email

Staff Status Any past or present restriction of privileges?

Yes No

(If Yes, explain. Attach additional pages if necessary.)

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SECONDARY FACILITY

Dept. Chairman

Date affiliation started Date affiliation ended (if applicable)

Address/Street

City/State/Zip

Phone Fax Email

Staff Status Any past or present restriction of privileges?

Yes No

(If Yes, explain. Attach additional pages if necessary.)

SECONDARY FACILITY

Dept. Chairman

Date affiliation started Date affiliation ended (if applicable)

Address/Street

City/State/Zip

Phone Fax Email

Staff Status Any past or present restriction of privileges?

Yes No

(If Yes, explain. Attach additional pages if necessary.)

SECONDARY FACILITY

Dept. Chairman

Date affiliation started Date affiliation ended (if applicable)

Address/Street

City/State/Zip

Phone Fax Email

Staff Status Any past or present restriction of privileges?

Yes No

(If Yes, explain. Attach additional pages if necessary.)

SECONDARY FACILITY

Dept. Chairman

Date affiliation started Date affiliation ended (if applicable)

Address/Street

City/State/Zip

Phone Fax Email

Staff Status Any past or present restriction of privileges?

Yes No

(If Yes, explain. Attach additional pages if necessary.)

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Provide information for all time frames (i.e. gaps) that are not covered in Education, Hospital Affiliations or Practice History

sections of this application such as extended travel, maternity leave, relocation, etc. If necessary, please attach an

additional sheet.

Dates From To Explanation:

SECTION VII

PROFESSIONAL REFERENCES

Please list three (3) Professional References familiar with your clinical abilities. These references MAY NOT be your residency

director, fellowship director, or current clinical department chairperson. This reference must be a “peer”, i.e. MD/DO to MD/DO, DPM to DPM, RN to RN, PA to PA, NP to NP, etc. If applying as a NP or PA, you may use one physician as a reference

NOTE: If applying to Grandview/Southview, applicant is required to provide at least 2 references that are current members of the medical staff.

Name

Address/Street

City/State/Zip

Phone Fax

Relationship Email

Name

Address/Street

City/State/Zip

Phone Fax

Relationship Email

Name

Address/Street

City/State/Zip

Phone Fax

Relationship Email

Name

Address/Street

City/State/Zip

Phone Fax

Relationship Email

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SECTION VIII

PROFESSIONAL LIABILITY INSURANCE COVERAGE

Provide professional liability insurance coverage information for the previous ten (10) years.

Not Applicable Reason

MALPRACTICE CARRIER

Carrier Name

Address/Street

City/State/Zip

Phone Fax Website

Policy number

Length of time with this carrier

If coverage with this carrier is less than ten (10) years, please list your previous carrier(s). (Attach additional pages if necessary) Amount of coverage (Per claim/Aggregate)

Type of coverage Occurrence Claims made

Effective dates (from/to)

Renewal date

Agent Name

Address/Street

City/State/Zip

PREVIOUS CARRIER

Carrier Name

Address/Street

City/State/Zip

Phone Fax Website

Policy number

Amount of coverage (Per claim/Aggregate)

Type of coverage Occurrence Claims made

Effective dates (from/to)

Agent Name

Address/Street

City/State/Zip

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SECTION IX

MALPRACTICE CLAIMS HISTORY

Name:

Date

Patient Name:

DOB:

Civil Action #: Date of Incident:

Date filed: Date Settled/Closed: Professional Involvement: Attending/Resident/Other

Diagnosis:0

Allegations:

Case Summary:

CASE RESOLUTION

Dismissed: Settled out-of-court: Litigated:

Venue:

Settlement paid on your behalf: Total Settlement:

PROFESSIONAL LIABILITY INFORMATION

Name of Insurance Carrier:

Policy Number:

Address:

PLAINTIFF’S COUNSEL

Name of attorney Phone Number:

Address:

OTHER APPLICABLE INFORMATION

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SECTION X

DISCLOSURE INFORMATION

Please answer the following questions “yes” or “no”. If your answer to any of the questions “yes”, please provide a written explanation on a separate sheet.

INSTRUCTION NOTE: A voluntary surrender or non-renewal is for reasons related to professional competence or conduct when the surrender or non-renewal is done to avoid an adverse action, preclude an investigation or is done while the licensee is under investigation related to professional competence or conduct.

1. Has there ever been any successful or currently pending challenges to any licensure, registration or certification; or has your license, registration or certification to practice in your profession, ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, or restricted; or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration or certification board or are any such actions pending?

Yes No

2. Have your clinical privileges or medical staff membership at any hospital or

healthcare facility, voluntarily or involuntarily, ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical records when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare facility, medical staff or committee, or governing board or are any such actions pending?

Yes No

3. Have you voluntarily or involuntarily surrendered, limited your privileges or not

reapplied for privileges while under investigation? Yes No

4. Have you ever withdrawn your application for appointment, reappointment, clinical

privileges and/or scope of service, or resigned from a medical staff before a decision by a hospital’s or healthcare facility’s governing body was rendered.

Yes No

5. Have you ever been the subject of disciplinary proceedings or investigations at any

hospital or healthcare facility or other medically related organization? Yes No

6. Has Medicare, Medicaid, or any other medical reimbursement plan ever voluntarily

or involuntarily suspended, limited, revoked, denied, not renewed or terminated your participation for reasons related to professional competence or conduct?

Yes No

7. Have you ever been denied membership or had your membership for participation

in any managed care organization (including HMOs, POSSs PPOs, or provider organizations such as IPA, PHOs) revoked, investigated, suspended, restricted, not renewed for cause; or have you ever been subject to any disciplinary action, by any managed care organizations; or have you ever voluntarily resigned from such an organization?

Yes No

8. Have you ever been or are you currently suspended, sanctioned, excluded or

otherwise precluded from participating in Medicare, Medicaid or any other federal, state or private funded health insurance program?

Yes No

9. Were you ever placed on probation, disciplined, formally reprimanded, suspended

or asked to resign during an internship, residency, fellow, preceptorship or other clinical education program? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign?

Yes No

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10. Have you ever, while under investigation or to avoid an investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program?

Yes No

11. Have any of your board certification or eligibility ever been revoked? Yes No 12. Have you ever chosen not to re-certify or voluntarily surrendered your board

certification(s) while under investigation? Yes No

13. Has your Federal DEA and/or State Controlled Dangerous Substances (CDS)

certificate(s) or authorization(s) ever been challenged, denied, suspended, revoked, restricted, denied renewal, or voluntarily or involuntarily relinquished?

Yes No

14. Has your professional liability coverage ever been cancelled, restricted, declined

or not renewed by the carrier based on your individual liability history? Yes No

15. Have you ever been assessed a surcharge, or rated in a high-risk class for your

specialty, by your professional liability insurance carrier, based on your individual liability history?

Yes No

16. Has any (current or past) professional insurance carrier(s) excluded any specific

procedures from your coverage? Yes No

17. Have you ever practiced medicine without professional liability insurance? Yes No

18. Have any professional liability suits been filed against you or have you received

written notice of intent to file such a suit? If yes, please complete Section IX. Yes No

19. Have any professional liability claims or suits been brought or filed against you,

which are presently pending/under investigation? If yes, please complete Section IX.

Yes No

20. Have any judgments been made against you or settlements rendered on your

behalf in any professional liability cases? If yes, please complete Section IX. Yes No

21. Have you ever been arrested for, charged with or convicted of any criminal

proceedings, including any charges pending; or been convicted of, pled guilty to, or pled nolo contendere to any felony of any degree?

Yes No

22. In the past ten years have you been arrested for, charged with convicted of, pled

guilty to, or pled nolo contendere to any misdemeanor (excluding minor traffic violations) involving fraud, OVI/DUI/DWI/OMVI an act of violence, child abuse or a sexual offense or sexual misconduct; or been found liable or responsible for any civil offense that is reasonably related to your qualification, competence, functions, or duties as a medical professional?

Yes No

23. Have you ever been disciplined for a violation of ethical standards by a

professional organization? Yes No

24. To your knowledge have you ever been the subject of a filed, pending or disputed

report to the National Practitioner Data Bank? Yes No

25. Do you have a history of engaging in the illegal use of drugs? (“Illegal use of

drugs” means the use of any controlled substances illegally obtained, i.e. not obtained pursuant to a valid prescription and not taken in accordance with the direction of a licensed health care practitioner.)

Yes No

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26. Are you currently engaged in the illegal use of drugs? (“Currently” does not mean on the day of or even the weeks preceding the completion of this application. Rather, it means recently enough so that the illegal use may have an impact on one’s ability to practice. The term does include, however, the unlawful use of prescription controlled substances)

Yes No

27. Are you currently in treatment for addiction to drugs or alcohol? Yes No 28. Do you use any chemical substances that would in any way impair or limit your

ability to practice medicine or to perform the functions of your profession with reasonable skill and safety

Yes No

29. Do you have any reason to believe that you would pose a risk to the safety or well

being of your patients? Yes No

30. Do you have any emotional or physical disabilities that may limit your ability to

practice? Yes No

31. Within the last five years, have you been reprimanded or disciplined in any manner by any state licensing authority or other professional board for conduct related to the use of alcohol or the use of any drug?

Yes No

32. Are you able to perform the procedures and the essential functions of the position

for which you have applied or requested privileges, with or without reasonable accommodation, according to accepted standards of professional performance and without posing a direct threat to patients?

Yes No

33. Do you or a member of your family own, have an investment in, or otherwise have

a business interest in any clinical laboratory, diagnostic testing center, hospital, ambulatory surgery center, or other business dealing with the provision of ancillary health services, equipment, or supplies?

Yes No

******************************************************************************************************************************************

34. If you are granted medical staff membership, clinical privileges and/or scope of service, do you agree to notify the Hospitals of any change to the foregoing answers upon the occurrence of any event, which would or does render any of the foregoing answer(s) incorrect or incomplete?

Yes No

35. Do you understand and acknowledge that it is an express condition to ongoing medical staff

membership, clinical privileges and/or scope of service to notify the Hospital(s) of any occurrence/event which renders the foregoing answers incorrect or incomplete when notice of the same is received by you?

Yes No

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SECTION XI

APPLICANT’S ATTESTATION & AUTHORIZATION OF RELEASE In applying for Medical Staff membership and/or clinical privileges at a Kettering Health Network (“KHN”) facility, I hereby signify my willingness to appear for interviews in regard to my application. I acknowledge that I have received and read the applicable Code of Conduct and the Medical Staff Bylaws and associated Medical Staff manuals of the Hospital(s) for which I am applying. I agree to be bound by the terms of said Code of Conduct, the said Bylaws and associated manuals as such Bylaws and manuals and Code of Conduct may from time to time be enacted/amended if I am granted membership or clinical privileges and/or scope of service and in all matters relating to the consideration of my application for appointment/reappointment to the medical staff and clinical privileges. I also understand, acknowledge, agree and attest to the following:

1. I acknowledge my obligation as a licensed health care professional to engage in my profession in a manner which is consistent with and in

compliance with all applicable federal and state laws. This includes, but is not necessarily limited to, all federal and s tate laws addressing the obligation to comply with conditions of participation for government sponsored health care entitlement programs. Consistent therewith, I have read the information provided in the HIPAA Review for Practitioners and I agree to abide by the principles set forth in that document. I further expressly agree to abide by the policies and procedures of the hospital as applicable to my professional practice and will also abide by the requirements of the Hospitals’ third party accreditation entities.

2. I agree to submit my clinical performance to, and faithfully participate in the Hospitals’ and KHNs’ performance improvement program(s) and I agree to hold the Hospitals, their Medical Staffs, and their directors, officers, members/employees, representatives and agents engaged in such quality activities free from all liability for their actions performed in connection therewith. I hereby consent for the Hospitals to notify the Montgomery County Medical Society, other hospitals, licensing boards, and other organizations concerned with provider performance and the quality and efficiency of patient care with any information relevant to such matters that the Hospitals may have concerning me and release the Hospitals, their Medical Staffs, and their directors, officers, members/employees, representatives and agents from liability for so doing. I further specifically acknowledge that the provisions the Medical Staff Bylaws and/or associated manuals relating to confidentiality and release from civil liability are express conditions to my application for, and acceptance/ continuation of Medical Staff membership and/or to the exercise of clinical privileges. I pledge to provide for continuous care for my patients and to fulfill such other responsibilities as may be required in the event I am granted Medical Staff membership and/or clinical privileges.

3. I understand and agree that I, as an applicant for Medical Staff membership and/or clinical privileges, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics and other qualifications for membership and clinical privileges as well as resolving any doubts about such qualifications. I attest that the information that I have provided is correct and complete, and understand that any significant misstatements in or omissions from the application or its attachments constitute cause for denial of appointment/privileges or cause for dismissal from the Medical Staff/termination of privileges. I understand and agree that if Medical Staff membership and/or requested privileges are denied or terminated based upon my quality of care or professional conduct/competence, I may be subject to reporting to the National Practitioner Data Bank and/or applicable State authorities. I further agree that in the event an adverse recommendation or action is made with respect to Medical Staff membership and/or privileges, I will exhaust the administrative remedies afforded by the Medical Staff Bylaws, if applicable, before resorting to formal legal act ion.

4. I agree to immediately notify the KHN Central Credentialing Office if any information contained in my application/reapplication or its attachments change. I further agree that the foregoing obligation shall be a continuing obligation so long as I hold Medical Staff membership and/or privileges at the Hospital(s).

5. I hereby further consent to the disclosure, inspection and copying of information in my Credentials file by and between the KHN Hospitals and KHN affiliated organizations and its/their representatives or other persons or entities who, in the opinion of the KHN Hospitals and its/their representatives, have a legitimate need for such information. I authorize and consent to the release by and between the KHN Hospitals and other KHN affiliated organizations and their representatives, all records and documents, including medical records, that may be material to an evaluation of my professional qualifications and competence for membership and/or clinical privileges herein requested, as well as my physical and mental health, and moral and ethical qualifications for membership and/or clinical privileges. I also consent to the sharing of credentialing, quality assessment, and peer review information by and between the KHN Hospitals to which I hereby apply, or where I already hold membership and/or clinical privileges. I understand that this may include sharing information received by any of them during this application or reapplication process and during any corrective action procedures, including but not limited to formal disciplinary hearings. I hereby release from liability such KHN Hospitals and other KHN affiliated organizations and their officers, directors, employees, liaisons, agents and representatives, including medical staff members, for their acts performed in good faith and without malice in connection with evaluating my application/reapplication and my credentials and qualifications, and I hereby release from any liability any and all individuals and other healthcare organizations who provide information to, or share information with the KHN Hospitals and/or KHN affiliated organizations in good faith and without malice, concerning my professional competence, ethics, character and other qualifications

for membership and/or clinical privileges. ____________(initial)

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6. I understand and agree that, as a condition of being appointed/reappointed as a member of the Medical Staff of any KHN Hospital to which I have applied, such Hospital or its agents may conduct a criminal records check; and my signature below constitutes my authorization for such Hospital or its agents to conduct such criminal records check. I hereby waive and release such KHN Hospital and it agents from any and all claims I may have with respect to any such criminal records check.

7. This authorization includes, but is not limited to, any and all information or documents related to licensure, federal or state controlled substance certification, medical education and training, medical board certification or eligibility, participation in Medicare/Medicaid and other public assistance programs, malpractice coverage and criminal history, kept in either hardcopy or electronic form, related to my status as a credentialed practitioner.

8. I have submitted a passport size photograph and give the right and my permission for Kettering Health Network (“KHN”) and any of its

affiliated hospitals, clinics and health centers with which I am associated to use and distribute this photograph and other professional biographical information for purposes of identification, world wide web publication, and other general public distributions in connection with educational, public relations, media relations, marketing, promotional, communications, and other charitable purposes.

9. ALL INFORMATION SUBMITTED BY ME IN THIS APPLICATION IS TRUE BY MY BEST KNOWLEDGE AND BELIEF.

10. I HEARBY AUTHORIZE THE RELEASE OF MY CREDENTIALING INFORMATION AS PROVIDED ABOVE.

Signature of Applicant Date

****************************************************************************************************************************************** REQUIRED FOR ALIIED HEALTH APPLICATIONS ONLY As the employing/sponsoring physician who will be supervising the applicant named herein, I state that the foregoing information provided is complete and accurate to the best of my knowledge and belief, and I hereby accept the responsibility for all activities performed at Hospitals. Signature Employing/Sponsoring Physician Date ________________________________________________

Printed Name Employing/Sponsoring Physician

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AUTHORIZATION FOR THE RELEASE OF INFORMATION AND LIABILITY

I hereby authorize and expressly consent for Kettering Health Network hereinafter called “Hospital(s)”, the members of Hospitals’ Medical Staffs, and the Hospitals’ employees, agents and representatives to consult with administrators and members of the medical staff and credentialing organizations, other hospitals, healthcare institutions, and healthcare providers with whom I have been associated and/or previously applied for medical staff appointment and/or privileges and with others, including past and present malpractice carriers, licensing agencies, peers, educational institutions, government programs, and credentialing reporting agencies which may have information bearing on my professional activities, competence, character, and/or ethical qualifications. I acknowledge that the Medical Staffs of the Hospitals are comprised of licensed physicians, podiatrists, psychologists and dentists who practice their respective specialty in and around Cincinnati/Dayton, Ohio and who have been granted medical staff appointment and/or clinical privileges at the Hospitals. The members of the Medical Staffs of the Hospitals are not, for purposes of credentialing and peer review processes and functions, employees of the Hospitals; but, rather, are licensed independent practitioners participating in Hospitals’ credentialing and peer review processes. I consent to the inspection by Hospitals, the members of its Medical Staffs, and its employees, agents, and representatives of all documents, including but not necessarily limited to peer review evaluation records, educational records, clinical competency evaluations, and credentialing files maintained by other hospitals or other healthcare institutions, that may be material to an evaluation of my personal and professional activities, professional qualifications and competence to perform and carry out the clinical privileges as requested, as well as my moral and ethical qualifications for medical staff membership and/or clinical privileges at Hospitals. I hereby release from and agree to hold Hospital, the members of their Medical Staffs, and the directors, officers, employees, agents, and representatives thereof harmless from and for any liability for performed in connection with evaluating my credentials, qual ifications, and application for medical staff membership and/or privileges. I further release from any liability, and hold harmless, any individuals or organizations who provide information to the Hospitals and the members of Hospitals’ Medical Staffs, concerning my past personal and professional activities, professional competence, ethics, character, and other qualifications for appointment and/or granting of clinical privileges and/or scope of service. I am willing to appear, if requested, for interviews in reference to my application or addendum.. I understand and acknowledge that Hospitals, the members of Hospitals’ Medical Staffs, and employees, agents and representatives thereof may be required to report to licensing agencies, (e.g. the State Medical Board), the National Practitioner Data Bank, and other credentialing and accrediting agencies or government entities information regarding my appointment, clinical privileges and/or scope of service, disciplinary action (if any) and professional conduct/competence which may otherwise be protected from disclosure as confidential peer review information. I hereby release from and agree to hold Hospitals, the members of Hospitals’ Medical Staffs, and employees, agents and representatives thereof harmless from and for any liability for the release of such information when Hospitals and/or its Medical Staffs, by and through their/members, employees, agents and/or representatives, disclose such information in compliance with such laws and regulations. I further understand that, pursuant to written authorization by me or a duly entered court order, the Hospitals, Medical Staffs, And the employees, members, agents and representatives thereof may provide to other hospitals, organizations, insurers, healthcare providers, reporting and accrediting agencies and other persons information concerning my professional competence, character, ethics, credentials and credentialing status, clinical privileges and/or scope of service status, appointment and other peer review information. I hereby release from and agree to hold Hospitals, Hospitals’ Medical Staffs and the members, employees, agents and representatives thereof harmless from and for any liability for release of such information, pursuant to my written authorization or a duly entered court order. I agree to sign such additional authorizations and release of information consent forms as may be necessary in conjunction with my application for medical staff membership or privileges at Hospital(s). A copy of this sign and dated authorization shall have the same effect as the original. Applicant’s Signature Date Print Name

23

AGREEMENT

I understand that it is a condition of Medical Staff membership/privileges that each practitioner has malpractice insurance coverage in the amounts of: $1,000,000 per incident and $3,000,000 aggregate I hereby agree to notify the KHN Central Credentialing Office at once if my current coverage is canceled, terminated or restricted in any way. SIGNATURE: PRINT NAME: DATE:

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****SEND DIRECTLY TO YOUR PROFESSIONAL LIABILITY INSURANCE CARRIER****

(this includes both recent past and current carrier)

STATEMENT OF AUTHORIZATION AND RELEASE FROM LIABILITY

Name and Address of Professional Liability Insurance Carrier:

POLICY #: To Whom It May Concern: I, , am applying for Medical Staff appointment, clinical privileges and/or scope of service at a Kettering Health Network facility(ies) and hereby authorize my professional liability insurance carrier to release to the individual and facility listed below all information regarding my claims history, including, but not limited to:

• Judgments entered

• Claims settled

• Cases pending

• Procedures not covered by my policy This information shall be submitted to:

Central Credentialing Office

Kettering Health Network

1 Prestige Place, Ste 550

Miamisburg, OH 45342

P: (937) 762-1300

F: (937) 522-9990 The above named person and Kettering Health Network, as appropriate, is to hereinafter be listed as a Certificate Holder and shall be notified of the amount of my coverage and any future changes in my insurance status. Your prompt and full response will be appreciated. My signature below constitutes consent to this inquiry, authorizes your response thereto, and releases you from liability for reporting/providing the requested information as specified above. Sincerely, ____________________________________________ ____________________________________ Signature of Applicant/Insured Date

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MEDICARE PHYSICIAN ACKNOWLEDGEMENT STATEMENT

By signing this document, I attest that I have received and read the following statement:

Medicare/TriCare payment to hospitals is based in part on each

patient’s principal and secondary diagnoses and the major

procedures performed on the patient, as attested to by the

patient’s attending physician by virtue of his/her signature in

the medical record. Anyone who misrepresents, falsifies or

conceals essential information required for payment of federal

funds may be subject to fine, imprisonment or civil penalty

under applicable federal laws.

Signature Date Print Name

26

KETTERING HEALTH

KETTERING HEALTH NETWORK #8637

PRACTITIONER INFORMATION

FULL NAME ________________________________________________________________________________________

Any Other Names Used _______________________________________________________________________________

Email address: ____________________________________________ (Provide if you prefer to receive information via email)

Social Security No. _______ /_____ / ___________ Date of Birth1 ______________________________________________

Current Address ______________________________________________________________________________________

City ______________________________________ State ________________ Zip _________________________________

Driver’s License State ____________________________ No. _________________________________________________

Have you ever been convicted of a crime?* Yes No

Offense ______________________________________ County ____________________ State __________ Date_________

Offense ______________________________________ County ____________________ State __________ Date_________

*To disclose additional criminal history, please provide those details on a separate sheet of paper and attach it to this form.

Please provide all locations where you have resided for the past seven (7) years, starting with your current residence. For

additional entries, please attach another sheet of paper.

City State Dates From: To:

1. __________________________ / _____________________ ________________________________________________

2. __________________________ / _____________________ ________________________________________________

3. __________________________ / _____________________ ________________________________________________

Nevada Private Investigator License # 1618

PRACTITIONER DISCLOSURE & AUTHORIZATION

STATE LAW NOTICES

Minnesota applicants or employees only: You have the right to request in writing from PreCheck, Inc., a complete and accurate written disclosure of the nature and scope of the report(s) requested by the Company. Place an X here _____ for a disclosure to be sent to you.

Oklahoma applicants or employees only: Mark an X here ____ for a free copy of a consumer report if one is obtained by the Company.

California applicants or employees only: Please mark this field ____ to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law.

California applicants or employees only: By marking an X in the designated field, you will receive and are acknowledging receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. _____

New York applicants or employees only: If an investigative consumer report has been requested by the Company, the name and address of the consumer reporting agency furnishing the report can be found on the following disclosure and authorization document. You have the right to inspect and receive a copy of the investigative consumer report by directly contacting the consumer reporting agency, PreCheck, Inc. In connection with the Company’s request for the preparation of a consumer report or investigative consumer report about you, the Company has provided you with a copy of Article 23-A of the New York Correction Law. Please mark this field to acknowledge receipt of a copy of Article 23-A: ____.

Maine applicants or employees only: If you are applying for a position in the State of Maine, you may request and promptly receive from the consumer reporting agency copies of all investigative consumer reports about you requested by the Company. The name and address of the consumer reporting agency furnishing the report can be found on the following disclosure and authorization document.

Massachusetts applicants or employees only: If you ask, you have the right to a copy of any background check report concerning you that the Company has ordered. You may contact the Consumer Reporting Agency for a Copy.

Washington State applicants or employees only: You have the right, upon written request made within a reasonable period of time after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of the investigation we requested.

I have read and understand the above information and assert that all information provided by me is true and accurate. Signature ___________________________________________________________ Date ______________________________ 1 The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age. This

information is necessary for the proper processing of a consumer report.

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NETWORK MED STAFF #8637

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Organization at any time after receipt of this authorization and throughout the term of my appointment, employment, contract or privileges, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance Organization to furnish any and all background information requested by PreCheck, Inc., 3453 Las Palomas Rd. Alamogordo, NM 88310; 1(888) PreCheck [1-888-773-2432] another outside organization acting on behalf of the Organization, and/or the Organization itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

By signing below, I confirm that I have read and understand the above information and that I provide my consent. Signature ___________________________________________________________ Date _____________________________

Nevada Private Investigator License # 1618

Kettering Health Network (“the Organization”) may obtain information about you from a consumer reporting agency made in connection with your application for appointment, employment, contract, or privileges. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding your criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other types of verifications requested by the Organization. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by PreCheck, Inc., 3453 Las Palomas Rd. Alamogordo, NM 88310; 1(888)PreCheck [1-888-773-2432] or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing the Organization to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your employment, contract, privileges or appointment to the extent permitted by law.

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

FULL NAME __________________________________________________________________________

Social Security No. ________ /______ / ______________ Date of Birth ______ / _______ / __________

www.PreCheck.com info@precheck.com ph: 800-999-9861 fax: (800) 207-2778

Ver. 0913

KETTERING HEALTH NETWORK #8637

PRACTITIONER INFORMATION

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PROFESSIONAL SANCTIONS REPORTING FORM

Name: Dept./Section: Date:

Facility Name:

Contact Person: Phone:

Date incident occurred: Status (check one): Pending Closed

Substance of allegations:

If closed, disposition (check one): Dismissed Disciplinary Action Taken

Substance of findings:

Additional Information (optional):

Name: Dept./Section: Date:

Facility Name:

Contact Person: Phone:

Date incident occurred: Status (check one): Pending Closed

Substance of allegations:

If closed, disposition (check one): Dismissed Disciplinary Action Taken

Substance of findings:

Additional Information (optional):

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MANDATORY: MUST BE COMPLETED IN ORDER TO RECEIVE PRIVILEGES

PLEASE FAX TO 937-395-8247

Attn: Melinda Cushman

In an effort to update the Emergency Department “Authorization for Treatment” records and expedite medical care of your private patients, please complete this form. Name (please print) Office Name Office Address City Zip Office # Home # Private Office # Fax Number # Beeper # Cell Phone # Med Society # Email:_______________________________________________________________________________

AUTHORIZATION: Please indicate preference after initial Emergency Department screening:

Contact me for routine notification of admission and/or referral.

Contact me upon arrival of patient.

Contact me after workup of patient.

Special Instructions:

REFERRALS: (Print legibly) List specialists to be called in the event specialist services are indicated. ***If NO PREFERENCE is listed, the specialist on the ED call rotation schedule will be utilized.*** Acute/Critical Care Oral Surgery Cardiology Orthopedics Colorectal Otolaryngology Gastroenterology Pediatrics General Surgery Plastic Surgery Hand Surgery Psychiatry Neurology Pulmonology Neurosurgery Thoracic Surgery OBGYN Urology Ophthalmology Hospitalist

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Annual Tuberculosis Assessment Form

Last Name: _________________ First Name: ______________ Date of Birth: _____/_____/_____

Status: Medical Staff Allied Health Staff

Do you note any of the following? (Please explain any “Yes” answers)

1. Constant cough for longer than three (3) weeks? Yes No

2. Chest pain? Yes No

3. Presently coughing up thick sputum or blood? Yes No

4. Currently having fever, chills or night sweats? Yes No

5. Constant tiredness, weakness or just not feeling well? Yes No

6. Loss of desire to eat? Yes No

7. A noted weight loss not related to dieting or exercise? Yes No

In the last year, have you: (Please explain any “Yes” answers)

1. Been exposed to or told you have “active” Tuberculosis? Yes No

2. Had a positive TB skin test or TB lab test? Yes No If YES, explain:

3. Known or cared for someone who has “active” Tuberculosis? Yes No If YES, explain:

4. Started taking Tuberculosis drugs? Yes No If YES, explain:

5. Worked in or lived in a long-term care facility? (Correctional facility/nursing home) Yes No

6. Traveled or lived outside of the United States? Yes No If YES, where:

7. Have you visited with family or friends who have recently come to the United States? Yes No If YES What

country? _________________________________________________________

8. Worked or been around homeless people? Yes No

9. Injected drugs or been around people who inject drugs or are substance abusers? Yes No

10. Been told you have an illness that has changed your immune system? Yes No

11. Had a surgery that has changed your immune system? Yes No

Signed: ____________________ Date: _____/_____/_____ Time: ____:____

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Kettering Health Network

Health Evaluation & Respirator Review Many network departments are required for licensure by the State of Ohio to obtain the following information. Please complete the following questions to the best of your knowledge. Plans can be made to talk about any medical questions you have. Please further explain any YES answer(s) in the space provided. All information will remain private and this form will be placed in your employee medical record.

1. Do any of your current health problems or conditions require work changes or affect your ability to do

your required job duties? If YES, please describe:

Yes No

2. Do you have any new allergies? If YES, please list:

Yes No

3. Do you currently have an infectious disease or have you had a serious infection since completing this form one year ago? (Hepatitis B, Hepatitis C & HIV disclosure is required for employees who perform

exposure-prone procedures) If YES, please describe:

Yes No

Annual Respirator Review

Respirator Brand & Model # PAPR (Powered Air Purifying Respirator) Other (N95): ___________________________

Please Answer the Following: 1. Have there been any changes in your health that will adversely affect your ability to wear the required

respiratory protection (PAPR or N95)? Yes No 2. Have there been any significant changes in your workplace environment that will adversely affect your

ability to wear a respirator? Yes No

3. Do you need additional training on PAPR or N95 use? Yes No 4. If you have been approved for an N95 respirator, have you had a 30 pound weight change over the last

year? Yes No If yes, how much? __________ pounds. 5. If you have been approved for an N95 respirator, have you had any of the following changes in the last

year: facial surgery or new dentures? Yes No

I certify that the information I have given is to the best of my knowledge.

Signature: ______________________________ Date: _____/_____/_____

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PES 2018 PHYSICIAN (and Allied Health Practitioner) EDUCATION in SAFETY

Human Resources 1/18 Kettering Health Network

CORPORATE INTEGRITY The compliance program at KHN is called the Protect Program. Our Compliance Officer is Robert Patterson. This program requires all personnel to do the right thing, even when nobody is looking, because it is the right thing to do. You have a duty to report any integrity concerns you may have to the

Corporate Integrity office or the confidential Hot Line (937-293-3344). The False

Claims Act makes it illegal to submit a false or fraudulent claim to the government for payment. This includes charging for services that are not medically necessary, charging for services never rendered, or missing documentation (i.e. missing physician signature). Penalties include triple the damages, plus fines of $5,000-$22,000 per claim.

The Stark Act prohibits a physician from referring patients to a healthcare provider if he or she has a financial relationship with that provider of any kind. KHN has a tool in place to track the amount of gifts to physicians, so that they do not exceed yearly

maximum. The Anti-Kickback Statute prohibits the knowing and willful payment of any kind to induce or reward referrals or the generation of business involving any item or service payable by KHN. Payment can include anything of value, including cash, free rent, meals, trips, entertainment, etc. It is against KHN Policy to accept gifts of any kind from vendors.

The Compliance Code of Conduct applies to all employees, officers, administrators, board members, medical staff, vendors, contracted employees, consultants, students and volunteers of KHN. The purpose is to inform KHN staff of the standards by which they are expected to conduct themselves. It is our hope that the Code will inspire staff to engage in appropriate conduct, not because of the requirements found within the Code, but because it is the right thing to do.

Physician Behavior / Impairment If a member of the Medical staff or Allied Health staff fails to conduct herself or himself appropriately; the matter shall be addressed in accordance with medical staff governance documents. It is the objective of the medical staff to ensure optimum patient care by promoting a safe, cooperative, and professional healthcare environment. This includes preventing or eliminating, to the greatest extent possible, conduct which disrupts the operation of the Hospital, affects the ability of others to do their jobs, creates a “hostile” work environment for hospital employees or other members of the Medical Staff, and/or interferes with an individual’s ability to practice competently.

KHN is committed to a Drug-Free Workplace. If you have concerns, please contact Employee Health.

KHN MISSION KHN is committed to improving the quality of life of the people in the

communities we serve through health care and education. The KHN Vision is to be recognized as the leader in transforming the healthcare experience. Everything we say

or do matters because every life matters. We embrace the KHN Values of being Trustworthy, Innovative, Caring, Competent, and Collaborative to help us rise to these

high standards. These values are encoded in our Standards of Behavior. We highlight the elements of Diversity and Inclusion to help us honor the dignity of every human being, and the contributions of every KHN employee

MEDICAL ETHICS The Four Guiding Principles of medical ethics are: Beneficence

(to Do Good), Non-maleficence (To Do No Harm), Respect for patient autonomy (safeguarding patients’ ability to make informed decisions about their medical care),

and Justice (being fair in the way we provide medical services). To resolve ethical conflicts, you must be able to take into account Medical Indications, Patient Preferences, the Particular Situation, and the Quality of Life that would result.

END OF LIFE CARE To provide comfort and dignity during end-of-life care, have respect for the patient’s and family’s cultural differences and conduct open

communication. The DNR Comfort Care or Comfort Care Arrest document requires signed physician orders. Refer to Administrative Policies Withholding/Withdrawal of Life Sustaining Treatment, Organ, Tissue, Eyes and Whole Body Procurement, Administrative, Advanced Directives, Patient Care Practice Standards, Patient Rights, Dying Patient, Patient Care Practice Standards, Pain Management, acute, or chronic.

Advance Directives include the Living Will and Durable Power of Attorney for health care. In a Living Will patients documents how they wish to be treated in case they have a terminal illness, but does not designate a representative who can make decisions for them. Once it is verified that a patient with a Living Will has become permanently unconscious, the attending physician must follow the instructions of the patient as stated on their Living Will. The physician must make a reasonable effort to notify the person or persons designated in the Living Will or closest family members if life-sustaining treatment is to be withdrawn. The law does provide that a family member may challenge the decision to withhold life-sustaining treatment. However; the challenge is limited in nature and may only be made by the patient’s closest relatives. In a Durable Power of Attorney for Health Care the patient chooses and names a person to make their health care treatment decisions for them when they are unable to do so. It goes into effect any time the patient is not able to communicate his or her own decisions, not only at the end of life.

PATIENT RIGHTS A list of patient rights and responsibilities can be obtained from

Patient Relations. Under HIPAA, patients have the right to privacy, and for their Patient Health Information (PHI) to be kept confidential. Do not share PHI with anyone who is not directly involved in the patient’s care, or who has a legal or regulatory right to see the information. When sending any sensitive or confidential data to anyone outside of KHN, encrypt the information by typing [Encrypt] in the email subject line. Any breach of confidentiality, security incident or concern must be reported to Corporate Integrity within 24 hours of discovery. All computer workstations

are the property of KHN. Informed Consent: Patients also have the right to make decisions about their care, including refusing treatment. This means that they must be given full and accurate information about their condition and treatment, including risks, benefits, alternatives, and the option of no treatment. The information must be given in a way that the patient can understand, and the patient should be able to verbally explain

what his or her treatment is in his or her own words. Pain Control Patients have the right to appropriate assessment and management of pain. Pain is whatever and whenever the patient says it is.

At KHN we see our work as a sacred calling. This is embodied in Called To Care, our effort to build a culture in which every patient receives the best care possible. We use

ICARE (Introduce yourself, Call the person by name, Ask, Respond, Express Thanks) as a model for patient interactions.

Restraints must be used only when necessary for safety, and limited to situations when less restrictive measures have failed or are not sufficient to protect patient and others from injury. The Patient’s rights, dignity and well-being must be respected at all times. The patient has the right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff.

The victims of Abuse, Neglect, and Human Trafficking can be any age. The abuse may be physical, emotional, sexual, or psychological. The goal of abuse often is to control the victim. Report all suspected cases of abuse, neglect, or human trafficking immediately to Social Services, Security/Police, SANE of Butler County, and the Nursing Supervisor.

Specific Populations: We show respect for patients when we are sensitive to Gender

Diversity. You can’t always tell a patient’s gender based on how they look or sound. Avoid mistakes by using gender neutral pronouns, or pronouns that match the patient’s gender identity. Call patients by their preferred name. Every patient has the right to be

treated in a caring and respectful manner. Provide Developmentally Appropriate Care by paying attention to patient demographics to help identify changing needs in

medication or nutrition, or to identify changes in a patient’s health status. Cultural

Competence means being aware of each patient’s culture, including his or her individual values, practices, and beliefs. Look for ways to involve patients’ spiritual or religious beliefs to promote healing. Contact Pastoral Care for more information. Show

compassion towards Patients with High BMI, recognizing that seeking medical care is often stressful for the obese patent.

QAPI is a quality assessment performance improvement program that must reflect all departments and services, including contracted services and must be developed, implemented, ongoing, and data driven. It focuses on identifying high risk

opportunities, and acting to reduce risk and errors. A Serious Reportable Event (SRE)

is an event that causes serious or irrevocable harm, or death. A Root Cause Analysis

(RCA) is an intense analysis of a near miss or sentinel event, which could also be a SRE. The purpose is to determine the cause(s) of the event, and to limit or eliminate the

chances of the event ever occurring again. Both RCA and Plan Do Check Act (PDCA)

are examples of Teamwork Approaches to Performance Improvement. LEAN is KHN’s culture of applying the scientific method for continuous improvement. It means creating more value for our customers while being more efficient with our resources.

GENERAL & EMPLOYEE SAFETY Fire Safety: Know where your area or

departmental pull stations are located, and your departmental fire plan. Electrical

Safety: Remove any malfunctioning equipment from use, and contact Biomedical Engineering. Do not use any equipment you have not been trained to use, or that is overdue for inspection. Breaker boxes require a 3-foot clearance at all times. Be aware

of the risks associated with exposure to Hazardous Drugs (HDs). Protect yourself by

using all appropriate Personal Protective Equipment (PPE). Safety Data Sheets (SDS) are located on the KHN intranet, with hard copies available in the Police/Security office.

Radiation Safety Use standard precautions when handling a Nuclear Medicine patient

to limit your risk of exposure. Report concerns to The Radiation Safety Officer. MRI

Safety No one may enter the MRI Suite or Trailer without pre-screening and approval from a certified MRI technologist.

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Back Care Healthcare workers are at a high risk of back injury. Care for your back by utilizing good ergonomics, regular stretches and exercise, and proper lifting techniques. This includes using mechanical lifting devices for patient transfers. If you have a Latex Allergy, please notify Employee Health. Use appropriate precautions when handling items that contain latex, including using latex free products (tape, gloves, etc.). Be careful when walking on slippery surfaces. Take slow, small steps, and wide turns at corners. Keep your arms at your sides. All hospital staff must wear an ID badge above their waist while on duty. Workplace Violence is any act or threat of physical violence, harassment, intimidation or other threating or disruptive behavior that occurs at the work site. If a person threatens you, immediately remove yourself from the situation and get help. Call Police/Security. Do not try to restrain the person yourself.: When faced with a dangerous situation, you must do something. Use Run, Hide, Fight to respond to an Active Shooter/Killer Situation. Another kind of workplace violence is Harassment. This includes racial or ethnic slurs or jokes, or derogatory comments based on race, religion, ethnicity or age. Sexual Harassment includes any unwelcome sexual advances, unwelcome physical contact, request for sexual favors, or other verbal or physical conduct of a sexual nature when submitting to or rejecting the conduct is used to make employment decisions or creates an intimidating, hostile, or offensive working environment. Sexual harassment will not be tolerated. All KHN staff are responsible for maintaining a

harassment-free environment, and reporting harassing conduct per the procedure in the KHN Harassment Free Workplace Policy. Reporting Incidents Report all employee safety incidents or injuries through the KHN Intranet by selecting S.A.F.E. Midas + RDE. Near-Miss Incidents occur when a patient or visitor intentionally commits a physical assault, or threatens or verbally abuses hospital staff, but no injury occurs. These should also be reported through S.A.F.E. Midas + RDE Forensic Patients are persons who are under arrest and brought to the hospital, or persons who must be maintained under watch. This watch is the responsibility of the arresting agency. Staff should notify Security/Police immediately when a forensic patient arrives at one of our facilities. Safe Haven for Newborns (Ohio law) allows parents to hand over a baby to an on-duty staff member at any hospital or law enforcement agency without facing child desertion charges if the baby is unharmed, the baby is less than 30 days old, and local law enforcement is made aware of the event. EMERGENCY PREPAREDNESS: Hospital plans for dealing with disasters are documented in our Emergency Operations Plan (EOP), found on the KHN intranet under “Emergency Operations.” Each hospital uses a Hospital Incident Command System (HICS) to help make sure information and direction flows to and from a single responsible authority so that necessary tasks can be performed efficiently. Utility Failure In a power failure, white receptacles operate uninterrupted and red receptacles powered by emergency generator operate after a ten second delay. Brown phones will be activated for use in a systems failure. CISM (Critical Incident Stress Management) is a tool to help KHN employees when something unusually or especially distressing occurs on the job. The Leader of the affected department will coordinate with the CISM trained Chaplain to determine the most appropriate interventions. PATIENT SAFETY 1. Improve the accuracy of patient identification. 2.

Improve the effectiveness of communication among caregivers. Verify orders – Write down, Read back. 3. Improve the safety of using high-alert medications 4. Reduce the risk of health care-acquired infections. 5. Accurately reconcile medications across the continuum of care. 6. Reduce the risk of patient harm resulting from falls. 7. Encourage patient’s active involvement in their care as a patient safety strategy. 8. The organization identifies safety risks inherent in its patient population. 9. Improve recognition and response to changes in patient’s condition. Note: standard “hand off” communication (Follow SBAR: situation, background, assessment and recommendation.) Label every medication and solution.

KHN has list of DO NOT USE abbreviations. Date and time verbal orders

Two Patient Identifiers: name and one of the following: date of birth, account #, or medical record #. Universal Protocol: Time out and surgical marking of site. Report an Adverse (or suspected) Pharmaceutical Reaction, by calling your local campus pharmacy. INFECTION CONTROL Standard Precautions are the minimum infection prevention practices that apply to all patient care in any setting where healthcare is delivered. Wash Your Hands frequently using the acronym WARD (Wet hands, Apply Soap, Rub and scrub for 15 seconds, Dry hands with towel and use towel to turn off the faucet) to prevent the spread of infections. Hands must be washed with soap and water any time they are visibly soiled (i.e. with blood or body fluids), when Contact with Handwashing precautions are posted (i.e. in cases of C-diff, norovirus), before and after eating, and after using the restroom. Use a golf-ball sized amount of foam Alcohol Hand Sanitizer both before and after putting on gloves, before and after touching patients or anything in the patient’s immediate environment, before performing aseptic tasks, if hands will be moving from a contaminated-body site to a clean-body site during patient care, and after contact with blood, body fluids or excretions, or wound dressings. Use Personal Protective Equipment (PPE), including eye protection, masks, gowns, gloves, any time a splash or contact with body fluids is possible. All sharps (includes used or unused syringes, bulb/asepto with or without needles, scalpel with blades, styles, loose needles, safety razors, guide wires, and broken glass) must be disposed of in a sharps container. Any exposure to Bloodborne Pathogens, such as a needle stick, splash or

sharps exposure, must be reported immediately to Employee Health, or if Employee Health is closed, to the Nursing Supervisor. Use a PAPR Respirator to reduce exposure to airborne disease (i.e. TB, SARS). Label specimens at the bedside with the patient present. Place specimens in a biohazard bag after the specimen has been labeled. STROKE AWARENESS Know the signs. Note changes in Face, Arms, Speech, and Time. At KHN Hospitals, summon the Stroke Rapid Response Team by dialing 11111. At other KHN facilities, dial 911.

CODE COLORS/EVENTS: These codes are standardized by the Ohio Hospital Association to enhance communications across the state. CODE ADAM: Infant/child abduction CODE BLACK: Bomb threat CODE BLUE/PINK: In the event of a cardiac or respiratory arrest; summon help by dialing 11111 or by pulling blue “code bar” above patient bed or in hallway of patient units. Code Blue for adults, Code Pink for 12 years and under. CODE BROWN: Missing Adult CODE GRAY: Severe weather warning. Remove people from external glass; cover patients with pillows/blankets, close curtains. CODE GREEN: Hospital Evacuation Plan CODE ORANGE: Hazardous Materials CODE PURPLE: Bioterrorism/Weapons of Mass Destruction (WMD) CODE RED: In the event of a fire, follow the RACE acronym. REMOVE people from the area. ACTIVATE 1) Activate alarm system 2) Call 11112, Give location. CONTAIN fire by closing door. EXTINGUISH fire, if practical. Pull, Aim, Squeeze, Sweep nozzle. CODE SILVER: Person with weapon/hostage situation CODE VIOLET: Violent/Combative Patient CODE YELLOW: Internal or external disaster. The Hospital Command Center, and Incident Commander will coordinate the response.

I HAVE REVIEWED THESE MATERIALS and AGREE TO COMPLY WITH THEM AT KETTERING HEALTH NETWORK FACILITIES. Signature: _____________________________________Date____________ PRINTED NAME: ______________________________________________ If you have any questions, contact, Human Resources. Fort Hamilton Hospital 513-867-2203, Kettering Physician Network 937-558-3232, Grandview Medical Center 937-723-3267, Southview Medical Center 937-401-6289, Greene Memorial Hospital 937-352-2100, Sycamore Medical Center 937-384-3887, Kettering Medical Center 937-395-8833, Soin Medical Center 937-702-4110

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HIPAA REVIEW FOR PHYSICIANS

What is relevant to a Kettering Health Network Practitioner

Introductory

This review addresses the requirements of the Privacy and Security rules under the Health Insurance and Portability and Accountability Act of 1996 (HIPAA). While reference is mainly made to the Privacy provisions, the Privacy and Security rules work in tandem in strengthening patient rights and privacy protections. The regulations boil down to 1) for the practitioner – more responsibility to protect the patient’s privacy, and 2) for the patient – more control. Primary reasons we comply with these requirements:

• It’s the law

• HIPAA supports our institution’s commitment to respect patient privacy and confidentiality

• Privacy violation complaints can jeopardize the hard earned reputation and respect of the institution and the individual practitioner

• It is part of the good care and services we provide our patients

Secondary reasons we comply with these requirements:

• Patients can file complaints directly with the Department of Health and Human Services (HHS)

• Violations are subject to both civil and criminal penalties

What are we protecting, and how?

Protected Health Information (PHI), which is any information about a patient that we (KHN) create or collect which can be linked back to an individual.

We protect PHI from uses (internal) or disclosures (external) that are not authorized by the patient or are not for appropriate use in treatment, payment or KHN operations.

Internally we must use PHI only to conduct the duties for which we are responsible. This is why only certain individuals have access to PHI and the level of access is controlled to minimize the ability to see certain PHI. This is what is called Minimum Necessary and Need-to-Know. This also applies to access in restricted areas of the hospital. Minimum Necessary also impacts:

• Looking only at the PHI of the patients for which you are involved in treating

• Do not look at your own PHI, your family member, or a friend. Unless you are participating in the care of this individual.

• Even when sharing information for treatment or payment purposes, make sure it is only what is necessary and appropriate

Safeguards

Safeguarding PHI can be time consuming and costly. For this reason, the regulations refer to reasonable

measures for protection of PHI. Here are a few tips:

• Although being overheard by others when talking to patients/family members in non-private rooms, small waiting areas, or other areas can be considered an incidental disclosure (this is an allowed type of disclosure under the regulation), we must make every effort to:

o Speak softly o Move to an area of the room where the most privacy is available o Use private rooms to communicate with family or patients, when available o Ask the family or patient if they feel comfortable discussing this information at the current

location you have chosen o Close and lock doors of/leading to rooms that hold PHI

o Do not leave documents with PHI where they can be accessed by others

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o Do not discuss PHI in public areas (e.g.hallways, elevators, etc.)

o Keep your laptop or personal digital assistant’s (PDA) secure, and with passwords if possible

o Dispose of documents with PHI in the available bins, not the regular trash

o Do not share your computer password or access to restricted areas with anyone under any circumstances

Patient Rights

Accounting of Disclosures

• Patients can request a list of the individuals/entities to which you disclosed their information. This means that you or your staff will have to log and track the disclosures you make to external entities for purposes other than treatment, payment or certain healthcare operations and for which no patient authorization was obtained.

Access to Medical Record

• Although the patient has always had this right, HIPAA enforces their ability to access the record in a timely manner.

Request to Amend Medical Record

• A patient can request in writing to have their medical record amended if they feel the information is incorrect. The practitioner responsible for the information in question determines if in fact a correction is or is not required. Even if the change is not made, a copy of the request is kept in the medical record.

Facility Directory

• A patient can choose to be excluded from the facility directory. At KHN this classification is known as a Do Not Announce (DNA). As a DNA the patient will appear to anyone calling or stopping by, as if he/she were not at our facility. This classification can be found on LastWord and several census reports. A patient who is not DNA, and therefore part of our directory can be reached by someone asking for him/her by full name. We can then provide patient location, and general condition of a non-DNA patient.

Family / Friend Involvement

• The patient chooses whom we can and cannot communicate with regarding their care. At KHN we ask the patient to provide one or two names that we can share information with. This person(s) then becomes our point of contact and we direct anyone else asking detailed information about the patient to the person(s).

Alternate Means of Communications and Restrictions to Use and Disclose PHI

• A patient can request to be contacted via an alternate route (e.g. number, different address, cell phone, etc.) The patient can also request that their information not be used or disclosed in a certain way. These requests must be evaluated individually to verify that KHN can assure 100% compliance before it is agreed to.

File a Complaint

• Patients can file a complaint regarding their privacy directly with the US Department of Health and Human Services. That information is provided to them in our Notice of Privacy Practices or they can

contact the KHN Privacy Officer to file their complaint.

For Privacy or Information Security related questions, please contact the Information Security and Privacy Officer at (937)

395-8581 or e-mail: privacy.officer@ketteringhealth.org.

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Epic

(Electronic Medical Record)

Training KHN is fully operational with the Epic electronic medical record, which includes order entry. As a new practitioner to Kettering Health Network you must either complete instructor-led Epic training or pass an online competency test. If you have used Epic in another network, you may test out at any time after submitting your application. If you have not used Epic or need a refresher, you can register for an Epic class. Epic classes occur once a week. We recommend attending training closer to your start date. If you have your badge, please bring it to class to allow the trainer to help set your Epic preferences. To obtain your badge contact your facility’s Medical Staff office after you receive your privileges. If you attend training before your privileges are granted, you will use a generic training ID. Once your privileges are approved, you have the option to return to training for an optimization session to set up preferences and support tools. Also, Clinical Informatics, Medical Informatics and the Epic training team are available for optimization and further personal set up by appointment. For Epic and Dragon class registration and the test out inquiry visit our internet page:

http://www.ketteringhealth.org/physiciansonly/classsignup/

For further questions email InformationSystemsTrainingCenter@ketteringhealth.org or call iSupport at 937-384-4500

to enter a ticket for the Training Team.

Thank you,

Information Systems Training Department