UCSDSCHOOL OF MEDICINE
VOLUNTARY AND NON-SALARIED CLINICAL FACULTYWARRANTY/ATTESTATION IN SUPPORT OF APPLICATION

I, the undersigned applicant, hereby represent and warrant to theUCSD School of Medicine that all information contained in the foregoing application is true, correct and complete in all material respects. I understand and acknowledge that any material misstatement in or omission from my application shall constitute cause for denial of this application and revocation of my faculty appointment.

I hereby warrant and attest as follows:

  1. I have a current, unrestricted license to practice medicine/surgery issued by the Medical Board of California (attach copy of current license).

Yes: License number:

No: Please explain:

N/A (not a physician)

  1. Has your medical or other professional license in any state, DEA certificate of registration, membership on any hospital medical staff, or clinical privilegesonany medical staff ever been or are currently being voluntarily or involuntarily denied, revoked, suspended, relinquished, withdrawn, reduced, limited, not renewed, placed on probation or currently under investigation?

No

Yes: Please explain:

  1. Have you ever had any misdemeanor or felony criminal convictions against you or are there any such charges pending against you?

No

Yes: Please explain:

  1. Have you ever been excluded by the federal government from participation in any governmental program or, to the best of your knowledge, been proposed for exclusion?You agree to notify the Compliance Officer or the University's Office of the General Counsel immediately upon your receiving written or verbal notification that you are proposed for exclusion from any governmental health care program.

No

Yes: Please explain:

  1. Do you hold current, active, unrestricted clinical privileges at any healthcare organizations?

Yes, unrestricted: Please identify below:

Yes, restricted: Please describe the restriction: and identify below:

No: Please explain:

If Yes, please identify the hospital or healthcare organization:

HOSPITALS/HEALTHCARE ORGANIZATIONS WHERE CURRENT UNRESTRICTED, ACTIVE STAFF PRIVILEGES HELD
FACILITY NAME / STAFF STATUS
PHONE NUMBER / DATES: FROM / TO
FACILITY NAME / STAFF STATUS
PHONE NUMBER / DATES: FROM / TO
FACILITY NAME / STAFF STATUS
PHONE NUMBER / DATES: FROM / TO
  1. Do you hold Professional Liability Insurance coverage of at least $1 million per occurrence and $3 million aggregate (required to practice medicine at UCSD)?

n.b. UCSD liability coverage for voluntary faculty is very limited and only covers teaching and supervision of trainees. It does not provide any coverage for the voluntary faculty member’s own lapses, acts or omissions.

Yes: Please identify below

No: If no

Not needed: UCSD teaching activities only

Other reason: Please explain:

MALPRACTICE CARRIER INFORMATION
NAME OF CARRIER / POLICY NUMBER / DATES OF COVERAGE
  1. Has your professional liability insurance ever been canceled, or has any professional liability insurer refused to renew your policy?

No

Yes: Please explain:

8. I UNDERSTAND THAT I HAVE AN ONGOING LEGAL DUTY TO IMMEDIATELY INFORM UCSDSCHOOL OF MEDICINE, IN WRITING, IF THE CALIFORNIA MEDICAL BOARD RESTRICTS OR REVOKES MY LICENSE, IF MY CLINICAL PRIVILEGES ARE LIMITED OR REVOKED OR IF MY PROFESSIONAL LIABILITY COVERAGE LAPSES, IS REVOKED OR EXPIRES OR IF ANY OF THE CIRCUMSTANCES DESCRIBED IN SECTION 1.B ABOVE OCCUR.

9.I UNDERSTAND THAT I MAY BE LIABLE FOR ANY & ALL MONETARY DAMAGES OR EXPENSES INCURRED BY THE REGENTS OF THE UNIVERSITY OF CALIFORNIA ARISING FROM OR RELATED TO ANY MISREPRESENTATION, BREACH OF WARRANTY OR BREACH OF MY ONGOING DUTY TO INFORM THE UCSD MEDICAL SCHOOL OF ANY OF THE ABOVE CHANGES IN LICENSURE, CLINICAL PRIVILEGES, OR INSURANCE COVERAGE.

10.I release from liability, to the fullest extent permitted by law, the Regents of the University of California, UCSD School of Medicine, all Medical School Representatives for their acts in connection with evaluating me, this application and my credentials, qualifications and experience.

11.I authorize and consent to the providing of any information bearing on my professional qualifications and competence, character and ethical qualifications byhospitals, health care organizations, state and federal agencies, medical schools, training programs, licensing authorities, professional liability insurance companies and professional associations and other organizations and individuals to UCSD School of Medicine and its representatives.

12.I release from liability, to the fullest extent permitted by law, all individuals, corporations and organizations who in good faith and without malice provide information, including otherwise privileged or confidential information, to UCSD School of Medicine and Medical School Representatives concerning my ability, training, experience, background, professional ethics, professional malpractice experience, character, physical and mental health, emotional stability and other qualifications relating to my application.

For purposes of this application, I understand and acknowledge that the term “Medical School Representative” includes The Regents of the University of California, its employees, its designees and committees; the Vice Chancellor for Health Sciences; and all UCSD School of Medicine administrative staff who have responsibility for collecting or evaluating or acting upon my application; and any authorized representative or any of the foregoing.

I understand, acknowledge and agree that I have the burden of producing adequate information for proper evaluation of my experience, background, training, ability, professional ethics and or resolving any doubts about these or any of the other qualifications for appointment as a member of the voluntary clinical faculty. I agree to provide such other and further information relating to the foregoing as the School of Medicine may require.

Date: / Signature:

PRINTED NAME:______

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