Professional Staff Credentialing Toolkit, 2012

Professional Staff Credentialing Toolkit, 2012

Sample 8. Application Form[1]

PROFESSIONAL STAFF APPLICATION (Medical/Dental/Midwifery/EC Nursing)
Surname / Given name(s)
HomeAddress / Street
City / Province / Postal Code
Tel. No. / Fax. No. / Home Email
BusinessAddress / Street
City / Province / Postal Code
Tel. No. / Fax. No. / Business Email
Cell. No. / OHIP Billing No. / Specialty Code No.
Appointment Requested (Privileges include appointment at both Hospitals, with exception of midwives)
I herby apply for membership in the Professional Staff in the Department of:
Specialty of:
Hospital / Associate / Supportive / Locum Tenens / Term Staff / Regional Affiliate
Licensure and Certification (Please attach proof)
Provincial College / Provincial College
Number / Date
Year / Month / Day
L.M.C.C – Number / Date
Year / Month / Day
Fellowship – College / Date
Year / Month / Day / Country
Certification – specialty (ies) / Date
Year / Month / Day / Country
Professional Liability Protection Coverage (Please attach proof of current coverage)
Canadian Medical Protective Association / Registration and Class Number: / Expiry Date
Other professional liability protection / Registration and Class Number: / Expiry Date
Education
Undergraduate Education
Course or Degree / University / Date
Medical, Dental, Midwifery, or Extended Class Nursing Education
Course or Degree / University / Date
Internship/Residency
Course or Degree / University / Date
PROFESSIONAL STAFF APPLICATION (Medical/Dental/Midwifery/EC Nursing)
Post-Graduate (other associations, memberships, research, publications, etc.)
Hospital Appointments (past and present)
Hospital Name / Department / Category of Privileges and Extent of Privileges / Dates
Medical, Dental, Midwifery or EC Nursing Experience (professional practice, teaching appointments, etc.)
If more space is required, please attach a separate sheet
Have you ever been denied, had reduced, suspended or revoked hospital privileges for which you have applied?
No / Yes – If yes, give date and particulars
Have you ever voluntarily relinquished part or all of your hospital privileges? (other reasons than relocating)
No / Yes – If yes, give date, particulars and outcome
Have you ever been the subject of disciplinary proceedings or malpractice litigation?
No / Yes – If yes, give date, particulars and outcome (if more space is required, attach a separate sheet)
Have you ever been the subject of criminal proceedings or convictions?
No / Yes – If yes, give date, particulars and outcome (if more space is required, attach a separate sheet)
Have you ever experienced any health problems that would affect your ability to carry out assigned privileges?
No / Yes – If yes, please discuss with the Department Chief / Chief of Staff/Chair of the MAC

Sample 8. Application Form 1

Professional Staff Credentialing Toolkit, 2012

PROFESSIONAL STAFF APPLICATION (Medical/Dental/Midwifery/EC Nursing)
Professional References
List the names and full address including postal code, telephone number, fax number and email of the three references closely associated with your training and/or practice. One reference must be the Chief of Staff/Chair of the MAC or the Chief of the Department where your last appointment was held. Each reference will be sent a Reference Questionnaire from the Chief of Staff/Chair of the MAC Office.
1. / Name / Title:
Address / Telephone: / Fax:
City / Province / Postal Code / Email:
2. / Name / Title
Address / Telephone: / Fax:
City / Province / Postal Code / Email:
3. / Name / Title
Address / Telephone: / Fax:
City / Province / Postal Code / Email:
Nature of Practice
Full-time / Part-time
Solo
Group (specify) ______Affiliation: ______
Preferred Start Date:
Year / Month / Day
Indicate the areas of clinical practice you intend to take special interest in (i.e. geriatrics, sports medicine, obstetrics etc)
Other Special Interests / Photograph
Languages spoken / Attach one current, passport-size photograph
Committee interests
Community involvement
ALL INFORMATION CONTAINED IN THIS APPLICATION IS STRICTLY CONFIDENTIAL

Sample 8. Application Form 1

[1]Adapted from source: Grand River Hospital and St. Mary’s General Hospital. This Sample is provided as an example of how a hospital can format its Application Form.