HEALTHCARE ENTITIES INFORMATION FORM FOR APPLICANTS

NAME OF APPLICANT:______

Name of Facility:MemorialHermannNorthwestHospital

Address:1635 North Loop West, Houston, Texas 77008

Telephone Numbers:(713) 867-2000 (Main Number)

(713) 867-4306 (MHNW - Medical Staff Office)

(713) 448-6464 (Central Credentialing Office)

Type of Entity:Not for profit

Services Offered:General Medical

Approximate size of Active Medical Staff:663

Administrator:Charles Douglas Ardoin, M.D., Chief Executive Officer

Number of Beds:200

Fees:(Initial Appointment)$250.00 for MDs

$100.00 for AHP’s

(Reapplication)$250.00 (N/A for AHP’s

(Reappointment Fee)$100.00 (MDs/AHP’s)

(Other)N/A

GENERAL INFORMATION

Emergency Medicine, Pathology, Radiology, Radiation Oncology and Anesthesiology services are contractual. Therefore, only individuals associated with the contractual groups are to apply for staff privileges. Privileges will not be accepted for membership unless applicant is affiliated with the contracting organization. Contractual groups must have coverage as stipulated in the contract. The minimal coverage of malpractice for staff privileges is $200,000/$600,000.

Board Certified (by a Board approved by the American Board of Medical Specialties, the Bureau of Osteopathic Specialties, the American Board of Oral and Maxillofacial Surgery, or the American Board of Podiatric Surgery) in the clinical specialty in which the applicant is requesting clinical privileges; or has recently completed an approved residency or fellowship program (approved by the Accreditation Council for Graduate Medical Education) in the clinical specialty requested; and must attain board certification by the appropriate board specialty within five (5) years of completion of residency or fellowship.

I understand that I am required to attend a minimum of 50% of the meetings of the Section/Service to which I am assigned during the Provisional year.

I understand that I must meet the credentialing and patient activity requirements to continue as a member of the Medical Staff.

I will submit the name(s) of the Practitioner(s) who agrees to provide clinical specialty coverage in the event that I am absent from the hospital. The name will be stated on the Specialty On-Call Form that is in the application packet.

I understand that I may participate in Emergency Room call. I will treat all ER patients regardless of their ability to pay.

I agree to abide by the Bylaws of the Medical Staff of MemorialHermannNorthwestHospital and policies of the facility.

PODIATRY INFORMATION

All Podiatric applicants to the Medical Staff must document the following:

Successful completion of a one year approved post-graduate Podiatric residency program;

Board eligibility or certification with either the American Board of Podiatric Surgery or the American Board of Podiatric Orthopedics;

Podiatrists wishing to use the operating room facilities must have Board admissibility granted by the American Board of Podiatric Surgery and must obtain certification by that Board within four years of completion of their residency requirement;

Applications for operating room privileges must include a copy of the list of surgical cases presented to and approved by the Board;

If certification is not obtained within four years, surgical privileges will automatically be revoked.

TRAUMA SERVICES INFORMATION

If you participate in Trauma services at MHNW, you are required to meet the requirements stipulated by the agency that provide Trauma designation.

A.General Surgery

1.Maintain Board Certification

2.Complete an average of 9 hours of trauma related continuing medical education per year

3.Maintain current ATLS certification

4.Participate in ER Call

5.Attend 50 % of Trauma Committee meetings per year

B.Emergency Medicine

1.Maintain Board Certification

2.Complete an average of 9 hours of trauma related continuing medical education per year

3.Maintain current ATLS certification

4.Attend 50 % of Trauma Committee meetings per year or designee

C. Orthopedic Surgery

1.Maintain Board Certification

2.Complete an average of 9 hours of trauma related continuing medical education per year

3.Participate in the ER Call

4.Attend 50 % of Trauma Committee meetings per year or designee

D. Anesthesia

1.Maintain Board Certification

2.Complete required CMEs as required by the Bylaws

3.Attend 50% of Trauma Committee meetings per year or designee

E. Neurosurgery

  1. Maintain Board Certification
  2. Complete an average of 9 hours of trauma related continuing medical education per year
  3. Participate in the ER Call
  4. Attend 50 % of Trauma Committee meetings per year or designee

I certify that I have read and fully understand this document and meet the requirements for medical staff membership at MemorialHermannNorthwestHospital. I will provide the necessary documentation requested and understand that failure to provide evidence of the above during the application process will result in my application being placed in the inactive files. Please forward the application for privileges as well as all documentation pertinent to those facilities to which I wish to apply.

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SignatureDate

01/06; 02/06; 03/06, 10/07, 01/08, 0308