MEMORIAL HERMANN HEALTHCARE SYSTEM

HEALTHCARE ENTITIES INFORMATION FORM FOR APPLICANTS

Name of Facility:Memorial Hermann The Woodlands Hospital

Address:9250 Pinecroft

The Woodlands, TX 77380

Telephone Numbers:(281) 364-2300 (Main Number)

(281) 364-2427 (Medical Staff Office)

(713) 448-6464 (Centralized Credentialing Office)

Type of Entity:Not for Profit

Services Offered:General Medical and Acute Care

Approximate Size of Medical Staff:810

Administrator:Steve Sanders

Number of Beds:252

Fees:Initial Appointment$250.00 for medical staff

$100.00 for residents just completing their Residency

$ 75.00 for Allied Health Professionals

Reapplication$250.00 (N/A for AHP’s)

Reappointment FeeA fee of $200.00 will be charged to process reappointment applications for members who, over the previous two-year period, have not had any admissions or consultations.

PRELIMINARY QUALIFICATIONS FOR MEMBERSHIP

Only applications which meet all of the following criteria will be processed.

Please note the following and make note of the requirements for hospital privileges:

PLEASE NOTE: Due to exclusive contracts being in place at Memorial Hermann The Woodlands Hospital, applications for Emergency Medicine, Pathology, Radiology, and Neonatology privileges will not be accepted for membership unless applicant is affiliated with the contracting organization.

Rev 5/10/2010

MEMORIAL HERMANN – THE WOODLANDS HOSPITAL

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How does our facility fit your practice plan?:______

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□**MANDATORY REQUIREMENT: Completion of the Online Module Breakthroughs in Patient Safety is required in order to applications to be considered complete. No applications will be considered for membership or privileges without completion of this module. Refer to the attached instructions to register for your account Complete steps 1 and 2 of the attached instructions. You will be notified once your temporary access has been granted. You MUST provide an e-mail address where we can contact you. You will receive 1 hour of Category 1 Ethics CME for completion of this module.** Please check the box to indicate you have completed steps 1 and 2.

I understand that I must have sufficient clinical activity to continue Medical Staff membership;

I will submit the name(s) of the Practitioner(s) who agree to provide clinical specialty coverage in the event that I am absent from the hospital (Specialty O n-Call Form included in the application packet);

Emergency Room call coverage and the treatment of all Emergency Center patients, regardless of their ability to pay, may be required as determined by the Department/Section;

I agree to abide by the Bylaws of the Medical Staff of Memorial Hermann The Woodlands Hospital.

Podiatrists: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 five years of completion of their residency requirement;

Applications for operating room privileges must include a copy of the list of surgical cases being accumulated/presented for Board certification, including surgical cases performed during residency;

If certification is not obtained within five years, surgical privileges will automatically be revoked;

Clinical surgical privileges offered to Provisional Podiatry members shall be limited to forefoot surgery. Upon completion of the Provisional period, Podiatry members may request hindfoot privileges providing that they meet the requirements approved by the Medical Executive Committee.

I certify that I have read and fully understand this document and meet the requirements for medical staff membership at Memorial Hermann The Woodlands Hospital. 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

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Printed Name

Instructions for Non-Credentialed Physicians in filling out On-Line Application

Go to

  1. Click on “Register for a New Account”

Located on the right side of the

“Sign On” page

  1. Follow the instructions for “Physicians” applying for an account:

► You must have a valid email address to complete the application

► Please have your Texas (Medical) License Number ready

► Last 4 digit of your Social Security Number (if you have one)

Note: As you reach PART 2 of the OnLine application,

please make sure to respond for Account Type = CME

  1. You will be contacted by your local Medical Staff Office (MSO) once

your “Limited Use” account is generated (in approximately

3 business days). You will be provided with:

  1. Account Username (save this) e.g. P1012345
  2. One-time use Temporary Password (xx****)

[xx = Your First & Last Initial **** = last 4 digit of your social security #]

You are required to change your password after signing for the first time

  1. You will be given a 14-day grace period to complete your On-Line required BIPS (Breakthroughs in Patient Safety)CME. Your application will not be considered complete until this module has been completed.
  1. You are asked to complete the required CME classes listed under CME section while your application is being processed . Please notify the Medical Staff Office @ once you have completed this module.

The Woodlands Medical Staff Office (MSO) contact:

Evelyn Starr281-364-2427

Rev 5/10/2010