INITIAL APPLICATION FOR PROFESSIONAL STAFF · INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF. All sections must be completed. “SEE CV” or blank sections will be returned

INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF

All sections must be completed. “SEE CV” or blank sections will be returned for completion. Mark “N/A” if not applicable.

Revised 03/12 1 of 18

Date: Dear:

We are pleased to provide you with the enclosed Vanderbilt University Medical Center (VUMC) Initial Appointment Application for Professional Staff. This packet includes the application for Professional Staff membership and clinical privileges (as applicable). This single or “one packet” has been developed to facilitate and expedite both the appointment of qualified applicants to the Professional Staff and enrollment with Vanderbilt Medical Group (VMG) Contracted Managed Healthcare Plan(s) and government payers as applicable.

The Medical Staff Bylaws and Rules & Regulations may be found at the following site:

http://vumcpolicies.mc.vanderbilt.edu/E-Manual/Hpolicy.nsf

Please review these documents as you will be expected to abide by them and agree to do so by signing the Acknowledgement and Signature form located at the end of this application.

Your application will be considered complete and ready for processing once all requested information has been received in the Provider Support Services (PSS) office and your Faculty Appointment (for billing providers) with the School of Medicine or School of Nursing has been verified. The submission of your application for membership does not automatically grant you Professional Staff membership and privileges. All applications must proceed through a verification and review process and must also be approved by the governing body.

Once your completed, signed, and dated application is received in the Provider Support Services office, the credentialing process may begin. The process generally takes 90 days, however in order to reach this 90 day benchmark, we recommend the following:

Provide Complete, Detailed Information – Complete all areas of the application, providing as much detail as possible. Do not refer to documents such as your CV or resume. Incomplete applications cannot be processed and will be returned to the applicant for completion. If additional space is required to provide all of the information required, please submit additional files or pages with your application.

Provide Accurate Information - The process may require less time if contact information, including accurate mailing addresses, telephone numbers, fax numbers and e-mail addresses is provided.

Be prepared to help – Your assistance may be required when, after several attempts, we are unable to obtain a response from a primary source.

If we can further assist you in this process, please contact Provider Support Services at (615) 322-3573.

Sincerely,

Provider Support Services

Return Address (US Postal Service, Fed-Ex, UPS) DO NOT RETURN VIA CAMPUS MAIL Provider Support Services 1500 21st Avenue South Room 4163 Nashville, TN 37212

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http://vumcpolicies.mc.vanderbilt.edu/E-Manual/Hpolicy.nsf




REQUIRED DOCUMENTS CHECKLIST

The following documents are required for all practitioners in order to fully process your application. If any of the documents listed below are not available at the time of submission of your application, please submit your application with a note indicating when the documents will be submitted separately. Copy of advanced degree diploma (i.e., MSN, Ph.D., etc.) and any additional Advanced Training

Certificates Copy of current Curriculum Vitae outlining education and practice history

o All date entries must be complete and include “From/To” and “MM/YY” information. o Gaps in time greater than 30 days require a written explanation

Copy of Original/Initial Tennessee professional license(s) with date(s) of issue and Copy(ies) of current renewal Tennessee license(s) with date(s) of expiration to appropriate licensing board. NOTE: If you do not have a TN license, documentary evidence of submission of application must be provided prior to submitting this paperwork. Failure to do so will result in a delay in processing your application.

Copy of current (unexpired) U.S. Government issued photo ID (i.e., driver’s license, passport) Copy of SIGNED social security card Copy of unexpired resuscitation certification (ACLS, BLS, Advanced Airway) as applicable Copy of current malpractice/professional liability insurance certificate. If clinical faculty and not

receiving coverage through Vanderbilt Self Insurance Trust Fund, please provide evidence of professional liability coverage.

Copy of current Federal DEA Registration Certificate (as applicable) Copy of DD214 (as applicable) Copy(ies) of Board Certification/Recertification (as applicable) Copy of NPI assignment letter Copy of faculty appointment letter for billing providers (facilitated by Department and separate from

credentialing and privileging) Copy(ies) of Notice and Formulary signed by all Supervising Physicians or the designated Primary

Supervising Physician (if applicable). Complete, signed, and dated Protocol Signature Sheet (as applicable)

Questions in the sections below may require that you provide full details by submitting additional pages or files with your application. Additional pages or files should also be submitted with your application as necessary to provide complete information if there is not sufficient space within this form. Professional Society Memberships (See Section I) Professional Liability/Malpractice (See Section K) Disclosure Information (See Section N) Ability to Practice (See Section O)

All sections of the Initial Application for Professional Staff must be completed. Sections that contain references to Curriculum Vitae (CV) only, or those left blank will be returned for completion. Sections which are not applicable must be marked “N/A”.

NOTE: The faculty appointment process is separate from the credentialing and privileging process, and is facilitated by your department. Please contact them directly for information regarding faculty appointments.

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APPLICATION FOR INITIAL APPOINTMENT TO THE PROFESSIONAL STAFF

A. PERSONAL INFORMATION Name should be listed as it appears on your license First Name Middle Name Last Name Suffix

Social Security Number Date of Birth Degree

Other Names by which you have been known ☐ Maiden ☐ Former ☐ Other

Birthplace City State ZIP

Marital Status

☐ Single ☐ Married ☐ Divorced ☐ Widowed ☐ Partnered

Spouse/Partner Name

Current email address

B. ADDITIONAL INFORMATION Copy of current (unexpired) US Government issued photo ID (i.e. driver license, passport) attached

☐Yes ☐No

NPI Number: Copy of letter attached

☐Yes ☐No

Are you a US citizen? (If “Yes”, skip to section C)

☐Yes ☐No If “No”, documentation of immigrant status attached

☐Yes ☐No

Do you have the legal right to work in the United States? ☐Yes ☐No

Country of Citizenship: Permanent Resident Status:

Alien Status: Alien Number:

C. MILITARY SERVICE/COAST GUARD: Branch Date Enlisted/Commissioned Discharge Type Discharge Date

Military Service Data: (Please check one) 01 ☐ Not Applicable 06 ☐ Reserve/Inactive 02 ☐ Individual Ready Reserve 07 ☐ National Guard - Active 03 ☐ Retired Reg/Reserved Commissioned Officer 08 ☐ National Guard – Inactive 04 ☐ Individual Mobilization Augmentee 09 ☐ Prior Military Service – Discharged* 05 ☐ Reserve/Active *If discharged please submit a copy of your DD214 Form with your application.

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D. OPTIONAL INFORMATION The information in this section is optional. If you choose not to respond, your application will not be affected in any way. If you respond, the information will be used for statistical reporting to entities such as State and Federal Government. Race/Ethnic Origin Gender

☐Male ☐Female Languages English Only

☐Yes ☐No Language 1 Language 2

E. CONTACT INFORMATION Home Address

City State ZIP

Home Phone Cell Phone Pager

Office Address Street Name and Number

City State ZIP

Office Contact Phone FAX

Are you accepting new patients? ☐Yes ☐No

Practice Coverage: Office Hours: Monday – Friday Saturday Sunday

After-Hours Covered By (Partners or Group Name)

Emergency On-Call Number Is this an answering service? ☐Yes ☐No

F. BOARD CERTIFICATION List all board certifications you possess and submit copies of original certificates with your application. First Board Certification Name of Board

Specialty

Certification Date Certificate Number Have you been recertified? ☐Yes ☐No

Recertification date

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Second Board Certification Name of Board

Specialty

Certification Date Certificate Number Have you been recertified? ☐Yes ☐No

Recertification date

G. GRADUATE EDUCATION AND TRAINING Please provide a complete chronological history beginning with your highest level of education to present. For gaps in time greater than 30 days, a written explanation must be submitted with your application including the name(s) and contact information of individual(s) who can verify the information. Graduate Training Graduate/Professional School Degree

Registrar/Verifying Office Name

Address

City State ZIP

Phone FAX

Attended From (MM/DD/YYYY): To (MM/DD/YYYY):

Additional Training 1 Graduate/Professional School Degree

Registrar/Verifying Office Name

Address

City State ZIP

Phone FAX

Attended From (MM/DD/YYYY): To (MM/DD/YYYY):

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H. HOSPITAL AND OTHER INSTITUTIONAL AFFILIATIONS List all hospital/health system affiliations where you have been employed, practiced, associated, or privileged for the purpose of providing patient care. DO NOT list affiliations that were part of your graduate training.

Local Hospitals Affiliation Dates (MM/DD/YYYY) Primary Facility

1. Baptist Hospital From__________ To__________ ☐Yes ☐No 2. Centennial Medical Center From__________ To__________ ☐Yes ☐No 3. Gateway Medical Center From__________ To__________ ☐Yes ☐No 4. Jackson-Madison County General Hospital From__________ To__________ ☐Yes ☐No 5. Maury Regional Medical Center From__________ To__________ ☐Yes ☐No 6. Middle Tennessee Medical Center From__________ To__________ ☐Yes ☐No 7. Nashville General at Meharry From__________ To__________ ☐Yes ☐No 8. Parthenon Pavilion From__________ To__________ ☐Yes ☐No 9. St. Thomas Hospital From__________ To__________ ☐Yes ☐No 10. Skyline Medical Center From__________ To__________ ☐Yes ☐No 11. Southern Hills Medical Center From__________ To__________ ☐Yes ☐No 12. Summit Medical Center From__________ To__________ ☐Yes ☐No 13. Sumner Regional Medical Center From__________ To__________ ☐Yes ☐No 14. Tennessee Christian Medical Center From__________ To__________ ☐Yes ☐No 15. University Medical Center (Lebanon) From__________ To__________ ☐Yes ☐No 16. Vanderbilt University Medical Center From__________ To__________ ☐Yes ☐No 17. Vanderbilt Stallworth Rehabilitation Hospital From__________ To__________ ☐Yes ☐No 18. VA Medical Center (Nashville) From__________ To__________ ☐Yes ☐No 19. VA Medical Center (Murfreesboro) From__________ To__________ ☐Yes ☐No 20. Williamson Medical Center From__________ To__________ ☐Yes ☐No

If you have current or past affiliations with hospitals other than those listed above, please list all of them below. Submit additional hospital affiliations with your application if necessary.

Hospital Affiliation 1 Facility Name

Med. Staff Office/Verifying Department

Affiliated From (MM/DD/YYYY): To (MM/DD/YYYY): Is this your primary facility? ☐Yes ☐No

Department Category

Address

City State ZIP

Phone Fax

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Affiliated From (MM/DD/YYYY): To: (MM/DD/YYYY) Is this your primary facility? ☐Yes ☐No

Department Category

Address

City State ZIP

Phone FAX



Affiliated From (MM/DD/YYYY): To (MM/DD/YYYY): Is this your primary facility? ☐Yes ☐No

Department Category

Address

City State ZIP

Phone FAX

I. PROFESSIONAL SOCIETY MEMBERSHIPS

Are you currently a member of a local, state, or national healthcare society? ☐Yes ☐No

Have you ever been denied membership, renewal thereof, or been subject to any disciplinary action (excluding action associated with lack of attendance or non-payment of fees) in any healthcare organization or professional society, licensing or certifying board, whether federal, local, or state, or have proceedings by any of these been instituted? *If “YES”, please submit full details with your application

☐Yes* ☐No

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J. WORK HISTORY Please provide a complete chronological history beginning with your highest level of education to present. For gaps in time greater than 30 days, a written explanation must be submitted with your application including the name(s) and contact information of individual(s) who can verify the information. Work History 1 Employer Name

Title/Position Contact Name

Address

City State ZIP

Phone FAX

Employed From (MM/DD/YYYY): To (MM/DD/YYYY):

Reason for Leaving

Work History 2 Employer Name


Address

City State ZIP

Phone FAX


Reason for Leaving



Address

City State ZIP

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Phone FAX


Reason for Leaving



Address

City State ZIP

Phone FAX


Reason for Leaving



Address

City State ZIP

Phone FAX


Reason for Leaving

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K. PROFESSIONAL LIABILITY INFORMATION AND DISCLOSURE QUESTIONS Beginning with current policy, list ALL of your professional liability carriers for the past 5 years including coverage during graduate training, as applicable. Current Liability Carrier Carrier Name

Address

City State ZIP

Phone FAX

Issue Date (MM/YYYY): End Date (MM/YYYY):

Policy Number Coverage Amount each incident Annual Aggregate Amount

Previous Liability Carrier 1 Carrier Name

Address

City State ZIP

Phone FAX




Address

City State ZIP

Phone FAX



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Address

City State ZIP

Phone FAX



Professional Liability Disclosure Questions Have any judgments or settlements ever been made against you or on your behalf in professional liability cases? ☐Yes* ☐No

Are any professional liability claims or cases currently pending? ☐Yes* ☐No Have you ever been denied professional liability insurance or has your policy ever been cancelled? ☐Yes* ☐No

*If the answer to any of the additional liability questions above is “Yes”, please submit full details with your application

L. PROFESSIONAL/PEER REFERENCES Provide the name and complete contact information for 3 healthcare providers as references from whom we may request specific written feedback. • All references must be comparably licensed or an independently licensed practitioner • Have personal knowledge of your clinical ability, ethical character, professional performance and ability

to work cooperatively with others • None may be related to you in any way • At least one reference must have had organizational responsibility for your performance (i.e.,

preceptor, department chair, section chief, etc.) Reference 1 Name Title/Position

At what location/facility did you work with this person?

Address

City State ZIP

Phone FAX Email

Do or did they provide direct supervision? If “Yes” please provide dates below. ☐Yes ☐No

Direct Observation Start Date (MM/YYYY): End Date (MM/YYYY):

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Reference 2 Name Title/Position


Address

City State ZIP

Phone FAX Email



Reference 3 Name Title/Position


Address

City State ZIP

Phone FAX Email



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M. LICENSURE List all State Professional Licenses (including Tennessee) you currently hold or have held (APN, RN, etc.) and submit copies of each license with your application. If you are not currently licensed to practice in Tennessee, you must provide documentary evidence that you have applied for a Tennessee license. Failure to do so will delay the processing of your initial appointment application. License 1 Name (exactly as it appears on license)

Issuing State Licensing Authority License Number

Issue Date (MM/YYYY): Expiration Date (MM/YYYY):

License 2 Name (exactly as it appears on license)









Drug Enforcement Administration (DEA) Registration I do not prescribe or write orders for scheduled drugs and I acknowledge this is prohibited without first obtaining a full schedule DEA. ☐Yes ☐No

Name (exactly as it appears on registration certificate) Registration Number

Issue Date: Expiration Date: Is your DEA full schedule?* ☐Yes ☐No

Please submit a copy of your full schedule DEA certification renewal with your application. VUMC requires a “fee paid” DEA registration in order to prescribe or write orders for scheduled drugs. *If your DEA does not have a full schedule please submit a full explanation with your application.

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N. DISCLOSURE INFORMATION

1. Have you, your license, or your participation with any of the entities below ever been investigated, involuntarily denied, revoked, suspended, not renewed, placed under probation, reprimanded, subjected to an adverse action or disciplinary action or otherwise limited or curtailed or have you voluntarily relinquished any of the items below in anticipation of disciplinary action or any of the previously listed actions occurring or are any of these actions pending? a. State Medical or other Professional License (including any out of state Professional License)? ☐Yes* ☐No b. DEA Registration or other applicable controlled substance registration? ☐Yes* ☐No c. Hospital or healthcare facility staff membership or privileges? ☐Yes* ☐No d. Medicare, Medicaid or other local, state, and/or federal government program participation? ☐Yes* ☐No e. HMO, PPO or other health plan participation? ☐Yes* ☐No

2. Has your standing with any of the following bodies been investigated, denied, revoked, suspended, reprimanded,

limited, curtailed, not renewed, placed under probation, subjected to adverse or disciplinary action or is any such action pending? a. Professional ethics committee? ☐Yes* ☐No b. Regulatory Agency (CLIA, OSHA, etc.)? ☐Yes* ☐No c. Professional Malpractice Insurance Company? ☐Yes* ☐No d. Professional Training School or Program? ☐Yes* ☐No e. If others, please specify. _________________________________ ☐ N/A ☐Yes* ☐No

3. Have you ever been under investigation for, convicted of, arrested for, charged with, or pled to, any crime (other

than minor traffic violations), including crimes involving child abuse/molestation? ☐Yes* ☐No

4. In addition to #3 above, have you ever been investigated for or found to be a perpetrator of child abuse, child sex abuse, or neglect by ANY local, state or federal agency, such as Child Protective Services? ☐Yes* ☐No

5. Have you been denied certification/recertification or been subject to any disciplinary action, (excluding action associated with lack of meeting attendance or non-payment of fees?) ☐Yes* ☐No

6. Have you ever been sanctioned by any other federal or state agency other than those specified above, including TennCare or Worker’s Compensation Board? ☐Yes* ☐No

7. Have you ever opted out of Medicare? ☐Yes* ☐No

*If the answer to any of the Disclosure Information questions above is “Yes”, please submit full details with your application.

O. ABILITY TO PRACTICE MEDICINE

1. Are you able to safely perform all of the essential functions related to the specific clinical privileges you are requesting with or without reasonable accommodations? ☐Yes ☐No* *If “NO”, please submit full details with your application.

2. Do you currently or have you in the past engaged in the unlawful use of drugs, including the use of prescription drugs, not under the supervision of a licensed health care professional other than yourself? ☐Yes* ☐No *If “Yes”, please submit full details with your application.

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APPLICATION APPROVAL CONDITIONS: In making application for membership, I acknowledge that I will abide by the bylaws of the hospital(s), participating organization(s) and the medical ethics of the applicable licensing boards of Tennessee. I agree to be bound by the terms thereof if I am granted membership. As a condition of re-appointment, I agree that I will not participate in any form of fee splitting. I agree to abide by the medical staff bylaws and rules and regulations of the hospitals, clinics and institutions or other organizations to which I have applied for membership or requested professional staff privileges. I agree to abide by the patient bill of rights for those institutions for which I requested consideration. I understand and agree that, as an applicant to the participating organizations and as an applicant for professional staff membership, I have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubts about such qualifications. I believe that I am qualified to perform all procedures for which I have requested privileges. I have not requested privileges for any procedure for which I am not qualified. I pledge to maintain an ethical practice, to provide for continuous care for my patients, and to refrain from delegating the responsibility for any aspect of the care of my patients to any practitioner not qualified to undertake that responsibility. I pledge to participate in the educational activities provided by the facility, to abide by the bylaws, rules and regulations of the Medical Staff and the Governing Boards, to accept committee assignments as appropriate, to be subject to review as part of the quality assessment program, and agree that neither the facility to which I am applying or any member of the medical staff will be liable for any communication made during the credentialing process. I will avoid unwarranted publicity, dishonesty in any financial commercialism and to refuse acceptance in money, goods, in kind- or any inducement whatsoever from consultants, practitioners, makers of surgical appliances, instruments, and pharmaceuticals or others, and to make my fees commensurate with the service rendered and with the patient’s rights, and to avoid discrediting my associates by taking unwarranted compensation. I further pledge to comply with all ethical standards in the Code of Conduct. ACKNOWLEDGEMENT AND SIGNATURE I attest that the information provided in or attached to this application is accurate and complete. I understand that a condition of this application is that any misrepresentation, misstatement, or omission from the application, whether intentional or not, may be cause for automatic and immediate rejection of this application and may result in the denial of membership and privileges and/or termination of any contract with any institution upon subsequent discovery of such misrepresentations, misstatements or omissions, and the hospital(s) or any other participation organization may immediately terminate my appointment, privileges, and/or membership. By my signature below, I further acknowledge and agree that I will promptly and fully report all information to the Credentials Committee(s) of each institution to which I am applying should any of the following occur: (1) any of the answers in the application change, (2) any situation arises which affects my ability to treat patients at any time after I have signed and dated this form, while my application is pending, or if I am appointed to the Medical Staff, Network or Foundation while I maintain membership.

Printed Name: ________________________________________________ Original Signature: __________________________________________ Date: ______________________

VANDERBILT UNIVERSITY MEDICAL CENTER Other Facilities ☐ Vanderbilt Hospital & Clinic* ☐ Vanderbilt Psychiatric Hospital* ☐ Monroe Carell Jr. Children’s Hospital at Vanderbilt*

☐ Meharry Medical Group* ☐ Nashville General Hospital at Meharry ☐ Cumberland Pediatrics, IPA

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INVESTIGATION CONSENT AND AUTHORIZATION: By applying for appointment to the professional staff of a hospital, for membership or participation in any other organization to which I am applying, I hereby signify my willingness to appear for interviews with regard to my application, and I authorize representatives of the hospital, clinical staff, representatives of the institutions or other organizations to consult with administrators and members of the medical staffs of other hospitals, medical associations, institutions, state medical boards or professional licensing authorities with which I have been associated. I further authorize a criminal background check and contact with other entities to obtain information, including but not limited to coverage and claims information from past and present malpractice insurance carriers who may have information bearing on my professional competence, character and ethical qualifications.

I hereby further consent to the release and inspection of all records and documents by and to any or all of the following: representatives of clinical staff, representatives of the institutions, the hospital, its medical staff, clinical staff, representatives of the institutions, third party payers, accrediting bodies and their authorized managed care designee. These records may include malpractice claims history, medical staff credentials files and any other pertinent records (including those at other hospitals with which I am affiliated) that may be material to an evaluation of my professional qualifications, clinical privileges requested, competency for enrollment into managed care health plans, ability to carry out my professional practice, as well as moral and ethical qualifications for membership and appointment to the professional staff of a hospital or clinic.

I present this information as part of this credentialing process in the expectation that its confidentiality and privacy will be preserved, and this information will be released or disclosed only as part of current and future credentialing, peer review and quality assurance processes, to the extent possible under State and Federal law.

WAIVER OF LIABILITY: I hereby release from liability all representatives of a Centralized Credentials Verification Service, Vanderbilt University, it’s trustees, employees and officers, participating organizations, the hospital, clinical staff and representatives of the institution for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications. I hereby release from liability any and all individuals and organizations who provide information to a hospital or its medical staff, clinical staff, representatives of the institutions and participating organizations, Vanderbilt University or the Centralized Credentials Verification, in good faith and without malice, concerning my professional competence, ethics, character and other qualifications for medical association, membership or participation in designated organizations for staff appointment and clinical privileges, and I hereby consent to release of such information.

INFORMATION RELEASE: I hereby further authorize and consent to the release of information and documents by the releasing institution(s) to other health care institutions, a Centralized Credentials Verification Service, or providers as long as such release of information is done in good faith and without malice. I hereby release from liability the releasing institution(s), its trustees, its employees, agents, officers, servants, faculty and staff in connection with sum provision of information.

APPLICATION PHOTOCOPY APPROVAL: By applying to any hospital or organization for privileges, I authorize the institution(s) checked in the previous section to provide any other hospital(s), managed care organization(s) or other organizations a copy of this application and agree that a photocopy of this application or a fax copy of this application and release shall be as sufficient as though I had duly executed the same in my own handwriting.

Printed Name: ______________________________________

Original Signature____________________________________ Date: ______________________

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APPOINTMENT/PROTOCOL APPROVAL FORM

Advanced Practice Registered Nurse/Physician Assistant

APPOINTMENT/PROTOCOL APPROVAL FORM The accompanying signatures serve to recommend the appointment of ___________________________ as ______________________________ in the Department of __________________________________ for a period not to exceed two years commencing ______________________. Practice location:

If applicable, (APRN/ PA) the accompanying signatures serve to confirm the attached list of evidenced based practice protocols/guidelines have been reviewed and approved by both the practitioner and supervising physician and are consistent with the practitioner’s scope of practice/delineation of privileges and specific to the patient population. [http://tennessee.gov/sos/rules/0880/0880-06.pdf]

Protocol review and revision will occur every two years consistent with the reappointment process.

SUPERVISING PHYSICIAN(S) 1. 2. (Name/Title) (Name/Title)

(Signature) (Date) (Signature) (Date)

APRN/PA Applicant:

(Name/Title) (Signature) (Date)

Chief of Service/Division:

(Name/ Department) (Signature) (Date)

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http://tennessee.gov/sos/rules/0880/0880-06.pdf




PROVIDER ACKNOWLEDGEMENT STATEMENT

Dear Provider:

In accordance with Regulation 42 CR 412.46, HCFA requires that Vanderbilt obtain a Provider Acknowledgement Statement at the time of appointment. When signed, the statement is an acknowledgement that you are aware of Medicare regulations pertaining to physician attestation for hospital billings to Medicare. Please sign the statement below and return it to Provider Support Services with your application. These federal regulations require that the statement be part of your file prior to patient contact.

Thank you for your cooperation.

C. Wright Pinson, MBA, MD Deputy Vice Chancellor for Health Affairs CEO of the Hospitals and Clinics Vanderbilt University Medical Center

Notice to Physicians: Medicare 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 or 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.

_____________________________________ ______________________________________

Provider’s Name (Please print or type) Signature

______________________________________ _____________________________________

Provider NPI No. (MUST be included) Date

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ELEMENTS OF INFORMED CONSENT

1. The nature of the patient’s condition;

2. The proposed surgical, medical or radiological procedure and the operative site (if applicable)

3. The benefits and risks of the proposed procedure(s) stating the frequently occurring and significant risks,

using the phrase, “including but not limited to: and state, “it is not possible to guarantee results”;

4. Explain treatment alternatives, including no treatment;

5. The consequences of no treatment;

6. Who will be performing the procedure and a description of the role of residents or others who may

perform significant portions of the procedure;

7. The risks of anesthesia;

8. Potential blood/blood product transfusions

9. The patient or patient’s legal representative should be given the opportunity to ask questions and receive

additional information as requested;

10. The patient must be able to “teach back”: Describe in his/her own words the procedure, the risks and

benefits, and what parts of his/her body will be involved;

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Vanderbilt Medical Group Designation of Agent

For Preparation and Submission of Forms, Applications and Check Authorization

I , hereby authorize the Director of the Vanderbilt Medical Group Business Office (or his/her duly appointed designee):

1. To act as a proxy agent for me in the preparation, signature when required, and submission of applications, authorization agreements and insurance forms. This proxy status is inclusive of creating a user account and logging into internet-based systems of the Centers for Medicare and Medicaid Services (CMS) – Identity and Access Management (I&A) System, National Plan and Provider Enumeration System (NPPES), and Provider Enrollment, Chain and Ownership System (PECOS).

2. To complete CMS Meaningful Use Attestation when qualified as an Eligible Professional, and

when appropriate certified EHR objectives and measures are met. I also consent to reporting of provider and practice level data for designated clinical quality measures as part of the CMS Physician Quality Reporting System (PQRS).

3. To release my signature electronically or by facsimile on all documents and applications

necessary for my enrollment into managed care health plans, with which VMG has a provider contract. I understand that release of my signature in this way shall be as sufficient as though I had duly executed the same in my own handwriting.

I am given the following assurances by the Director of the Vanderbilt Medical Group Business Office (or his/her duly appointed designee): a. Insurance claim forms will be prepared only in those instances where I have submitted an

appropriately documented charge as supported in the medical record. b. That all insurance proceeds made payable to me will be entered in my revenue accounts.

4. Through the Payments Section of the Vanderbilt Medical Group to restrictively endorse and

deposit to an Account of Vanderbilt University all checks made payable to me received as payment of fees for professional services rendered by me to or on behalf of my patients pursuant to provisions of the Vanderbilt Medical Group Bylaws. This authority will continue until the same is revoked in writing.

Signature Approval Date

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VANDERBILT MEDICAL GROUP PARTICIPATION AGREEMENT

WHEREAS, the undersigned Participating Member desires to engage in the group practice of rendering professional services in the care of patients as a member of the Vanderbilt Medical Group (VMG), and VMG desires that Participating Member engage in professional practice as a member of the VMG;

NOW, THEREFORE, in consideration of Participating Member’s employment by Vanderbilt University and participation in the VMG, it is agreed as follows:

1. Bylaws. Participating Member agrees that he/she has received, read and will abide by the Bylaws of the VMG, which bylaws are hereby incorporated by reference and made a part of this Participation Agreement.

2. Group Practice. Participating Member shall not engage in any professional activities in the care of patients except in accordance with the standards and conditions set forth in the Bylaws of the VMG and/or as established by the Board of Directors of the VMG.

3. Fees. Reimbursement and fees for all of the professional patient care services rendered by Participating Member shall be endorsed over to and shall be the property of Vanderbilt University.

4. Health Plan Contracts. Participating Member shall enroll in any and all health insurance plans as participating member of the VMG, and may not contract with, or opt out of, any health insurance plan, including but not limited to the Medicare program, except as a member of and together with the VMG. Agreed to and Accepted by: Participating Member ______________________________ (Signature) ______________________________ (Printed Name)

______________________________ (Department Chairman Signature)

______________________________ (Printed Name)

______________________________ Department

VANDERBILT UNIVERSITY by and through its SCHOOL OF MEDICINE By: ___________________________ Title: _________________________ ______________________________ (Printed Name)

Date: _________________________

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04/03/07

1. Name of Physician 2. Degree Code - For Risk Management Use Only

3. Effective Date 4. SSN or Employee ID # 5. Department 6. Division 7. Specialty

8. Physician Status: Fellow ________ Faculty ________ Fellow with Faculty Appointment ________

9. Full Time: ________ Part Time: ________ Clinical Hours Per Week ________

10. Please circle time to Veterans Administration (VA): 0 1/8 2/8 3/8 4/8 5/8 6/8 7/8 8/811. Check all that apply.Surgical Specialties

80140 Bariatric Surgery 80225 Orthodontics/Dentistry 80474 Pediatric Surgery80425 80156 Plastic Surgery

80177 Podiatry (Procedures)80141 Cardiac Surgery 80154 Orthopedic Surgery 80132 Surgical Oncology80115 Colon/Rectal Surgery (other than Trauma) 80144 Thoracic Surgery80143 General Surgery 80155 Otolaryngology/Plastics 80171 Trauma80167 Gynecology Surgery 80170 80145 Urology80152 Neurosurgery 80146 Vascular Surgery80153 OB Delivery 80106 Other (please explain)80159 Oral Surgery

Other Specialties80254 Allergy 8022280151 Anesthesiology80255 Cardiology / No Procedures 80471 Neonatology 72401 Psychology80422 80261 Neurology 80469 Pulmonary Medicine/Critical Care

80248 Nutrition Do you attend in ICU? (please circle)

80234 Clinical Pharmacology 80466 YES or NO

80960 CRNA 80429 Radiation Oncology80256 Dermatology / General 80233 Occupational Medicine 8049180456 Dermatology / Procedures 80263 Ophthalmology (No surgery)

80424 ED (Fast Track Only) 71801 Optometry 80253 Radiology, Diagnostic / No Procedures80102 Emergency Medicine 80266 Pathology / No Procedures 7180080257 General Internal Medicine 80292 Pathology / Procedures80267 General / Medicine Pediatric 80235 Other (please explain)80446

80250 Podiatry / No Procedures80249 Psychiatry

Please check the following medical techniques or procedures you perform:

Angiography EndoscopyArteriography ERCP (Endoscopic retrograde cholanglopancreatogarphy)Bone Marrow Harvest Lasers - used in therapyBronchoscopy (rigid or flexible) Lympangiography

Mohs Surgerydoes not include: Myelography 1. Occasional emergency insertion of pulmonary wedge, Needle Biopsy

pressure recording catheters. Pneumatic or mechanical esophageal dilation 2. Urethral Catheterization Radiopaque dye injections into blood vessels, lymphatics, sinus tracts 3. Umbilical cord catheterization for diagnostic purposes or for and fistulae

monitoring blood gases in newborns receiving oxygen. Transesophageal EchocardiographyColonoscopy Other ________________________________________Dermatology Faculty - Advanced Dermalogic Surgery

Budget Number to be charged: _________________________________________ (Please provide only one budget number.)

Physician/CRNA Signature & Date Department Administration Signature & Date Verifying Completion of Form

Medicine or Pediatric Specialty - No Procedures (Diabetes, Endocrinology, Hematology/Oncology, Infectious Disease, Rheumatology, Gastroenterology, Nephrology, Child Development, etc)

Cardiology / Procedures (see procedure list below)

Otolaryngology Head & Neck SurgeryOtolaryngology (all types OTHER than major Head & Neck Surgery & Plastics)

Ophthalmology / Surgical Procedures

12. If not in Anesthesia, critical care, or a surgical discipline please review the following lists and check all that apply. If you perform or may be called upon to perform or supervise any of these procedures at least once a year, we need to know for appropriate insurance coverage.

Catheterization-Arterial, cardiac, or diagnostic, but

PROFESSIONAL LIABILITY APPLICATION

* Clinical hours must include time devoted to inpatient rotations, scheduled clinics, participation on consult service, supervision of fellows & residents in their care and clinical responsibilities and must include on call time, including nights, weekends, and holidays.

(including other weight reducing procedures)

Radiology Procedures / Interventional (includes dye injections & Nuclear Medicine)

Research - Patient Oriented, but NO patient care, no resident supervision of any kind

Physical Medicine & Rehab /

Sports Medicine

OB / GYN Outpatient or Clinic Visits Only

Medicine or Pediatric Specialty - Procedures (see procedure list below) - Diabetes, Endocrinology, Hematology / Oncology, Infectious Disease, Rheumatology, Gastroenterology

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Submit Application with attached PAF and Faculty Appointment Letter to: Clare Thomson-Smith, MSN, RN, JD For questions call 343-7566 or 322-4664 Chair, Professional Staff Billing Committee (May fax copy for initial review to 343-8646, Vanderbilt University Medical Center must have original on file for approval) A 1222 MCN Nashville, TN 37232-2183

PROFESSIONAL STAFF BILLING APPLICATION

Name: Department: Title: Nurse Practitioner Physician’s Assistant Psychological Examiner Genetics Counselor Certified Nurse Midwife PhD Psychologist Licensed Therapist Other The following questions are to be answered by Department/Division Employing Applicant: 1. What is the employee’s academic appointment? SON SOM

(Faculty appointment letter must be attached with this application)

2. What is the home department cost center # of the employee? Job Code? 3. Salary Responsible Entity: Hospital Dept/Division VMG Admin [David Posch] SON Owned

4. Department Business Officer and/or Billing Manager (Name contact for information and notification)

Name: Title: Phone#:

5. Please list the funding sources of the employee’s salary [should match with PAF]: (PAF must be attached with this application)

Center # Center Name %



If grant funded, explain:

6. Please indicate the following:

Site(s) of service:

Supervising Physician:

Mapped to Epic Dept # and Center #

Responsible party for completing income distribution form (IDF)

Name: Title: Phone#: 7. Indicate if this will be a new position or replacement position. New Replacement

8. FTE Status: Chairman’s Signature Date Billing Committee: Approved Rejected Committee Chair Signature Date

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AUTHORIZATION AND RELEASE TO: State Volunteer Mutual Insurance Company FROM: License # RE: Release of Information to Vanderbilt University Medical Center fax#343-8711 DATE: Policy#: State Volunteer Mutual Insurance Company (“SVMIC”) is the carrier of my medical/professional liability insurance, and as such SVMIC maintains certain information regarding my medical/professional practice, and specifically the history of any malpractice claims against me. I understand that this information is extremely sensitive and confidential. I acknowledge that SVMIC is protective of this information and will only release it upon my express and unambiguous consent and direction. I have decided, for reasons related to my practice, that certain information from SVMIC should be directed to Provider Support Services, Vanderbilt University Medical Center. Therefore, I request that SVMIC deliver to 4163 Village at Vanderbilt, Nashville, TN 37232-8678 information relating to the following:

A report of any medical professional liability claims activity against me on record with SVMIC, but specifically limited to:

1) Claims that have resulted in paid losses (settlements), and/or 2) Lawsuits (open or closed)

I hereby authorize SVMIC to release the information requested to Provider Support Services and I consent to its use by Vanderbilt University Medical Center.

I HEREBY RELEASE SVMIC, ITS OFFICERS, DIRECTORS, EMPLOYEES AND AGENTS FROM ANY CLAIMS, LIABILITIES, ACTIONS, DAMAGES, OR OTHERWISE, FOR THE RELEASE OF SUCH INFORMATION IF SUCH RELEASED INFORMATION IS DELIVERED IN GOOD FAITH AND WITHOUT MALICE. I ALSO ACKNOWLEDGE THAT MISTAKES MAY OCCUR IN THE PROVISION OF SUCH INFORMATION, AND, WITHOUT LIMITING THE FOREGOING, I SPECIFICALLY RELEASE SVMIC, ITS OFFICERS, DIRECTORS, EMPLOYEES, AND AGENTS FROM ANY CLAIMS DUE TO INCORRECT, MISDELIVERED, OR OTHERWISE INAPPLICABLE INFORMATION IF SUCH ERRORS OCCURRED IN GOOD FAITH, AND UPON DISCOVERY, SVMIC TAKES REASONABLE CORRECTIVE ACTIONS. THIS AUTHORIZATION WILL REMAIN IN EFFECT UNTIL SPECIFICALLY REVOKED BY ME IN WRITING. SIGNATURE

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DO NOT DUPLICATE

PreApp Rev 13 12/15/04

BLUECROSS BLUESHIELD OF TENNESSEE, Inc. (BCBST) PRACTITIONER PRE - APPLICATION

(Includes MDs, Physician Extenders and Health Care Practitioners) Completion and acceptance of this Pre-Application by BlueCross BlueShield of Tennessee, Inc. is not a guarantee of Network Participation.

Appeals related to this Pre-Application will be governed by BlueCross BlueShield of Tennessee, Inc. policies and procedures. Pre-Application must be completed in its entirety, including the Professional History section. Please complete carefully and legibly.

Name ________________________________________________, ________________________________________________, _________, ________________ Last First Mid. Int. Degree Group Practice Name: _______________________________________________________________________________________________________________ Primary Office Location: ____________________________________________________________________________ Phone # (______)___________________

(Please list all other locations, City, State, Zip and County on a separate sheet of paper and attach to pre-application.) City: _________________________________________ State: _______________ Zip: ____________ County (TN or Contiguous) _____________________________________ Social Security Number: _________________________ Date of Birth:____________________ Gender: M or F Primary Specialty: _______________________ Secondary Specialty: ______________________ Licensure Number: ______________ State Issuing License: ______ DEA Certification Number: ____________ APN Licensure Number (CRNAs, NMWs, NPs): ____________________________ RN Licensure Number (CRNAa, NMWs, NPs): _______________________ Name of Medical/Professional School(s) attended: ____________________________________________________________ Date of Graduation: _____/____/___ MM / DD / YY Address: ____________________________________________________________________________________________________________________________ Office Contact Name and Title ___________________________________________________________________________________________________________

CHECK NETWORKS APPLYING FOR: _____ Blue Network C _____ Blue Network P _____ Blue Network S _____Blue Network K ____ BlueCare® _____ TennCareSM Select _____ BPN

Provider Responsibilities 1) Do you have malpractice insurance coverage for a minimum of at least $1,000,000.00 per claim and $3,000,000.00 in the aggregate? ___ Yes ___ No

a) If the answer is No, do you only work for the State of Tennessee? ______ 2) Do you have admitting privileges with a BCBST network hospital? ________ If Yes, at which hospital(s)

___________________________________________________ a) If No, please list BCBST practitioner providing your provision for coverage and BCBST hospitals where he/she has admitting privileges ________________________ b) If you are a nurse practitioner, physician assistant or certified nurse midwife, please enter your preceptors’ name and BCBST network hospital where he/she admits:

_______________________________________________________________________________________________________________________________________________

Professional History Please read the following questions carefully.

No Yes 1. ( ) ( ) Are you currently practicing with an invalid or expired license? 2. ( ) ( ) Is your license to practice restricted? 3. ( ) ( ) a. Has your medical license been revoked or not renewed (a license "revocation") by any jurisdiction within the last two (2) years, for cause, or have you surrendered your license to avoid such a revocation? b. If answer to 3.a. is yes, please indicate date license was re-issued. ______________________ ( ) ( ) c. Do you have a license revocation action pending or initiated against you? 4. ( ) ( ) a. Has your Drug Enforcement Administration Certificate(DEA) or Controlled Dangerous Substances Certificate(CDS) been revoked, or not renewed (a "revocation") by any jurisdiction within the last two (2) years, for cause, or surrendered to avoid imposition of such revocation? b. If yes, please indicate date(s) DEA and/or CDS certificates was/were re-issued. DEA _____________ CDS _______________ ( ) ( ) c. Do you have DEA or CDS certificate revocation actions pending or initiated against you? 5. ( ) ( ) Have you been convicted of fraud, felony, or any offense involving moral turpitude by any jurisdiction within the last two (2) years, or is such action pending or been initiated against you? 6. ( ) ( ) Are you currently sanctioned by Medicare or Medicaid? (e.g. excluded from participation in Medicare or Medicaid Program(s))

CERTIFICATION OF PROFESSIONAL HISTORY and PROVIDER RESPONSIBILITIES As a condition of my participation in any BCBST product network, I agree to maintain general liability insurance coverage with reasonable limits and worker’s compensation insurance coverage in accordance with applicable state law. Further, I agree to maintain such coverage continuously while participating in any BCBST product network, and will provide acceptable proof of such coverage to BCBST upon request.

I, the undersigned practitioner, certify that the above and any additional information provided is complete, accurate, and true. I acknowledge that falsification, inaccuracy, or failure to fully disclose any information requested is grounds for rejection of practitioner’s application for any BCBST Provider Networks. I hereby authorize BCBST to query the National Practitioner Data Bank (NPDB) and the Healthcare Integrity and Protection Data Bank (HIPDB) and further release BCBST from any and all liability arising from querying and reporting to the HIPDB as required by 45 CFR Part 61, except to the extent BCBST has actual knowledge of the falsity of the reported information. I further agree that any dispute relating to or arising in connection with this application must be resolved in accordance with applicable BCBST policies and procedures. Date: ______________________________ Signature: ____________________________________________________________________________________________________

Please print name of Provider Relations Representative submitting Pre-Application: _____________________________________ Date: ____ _________

For BCBST Use Only:

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Documents

INITIAL APPLICATION FOR PROFESSIONAL STAFF · INITIAL APPOINTMENT APPLICATION FOR PROFESSIONAL STAFF. All sections must be completed. “SEE CV” or blank sections will be returned