Ap pendix 6.1 MEDICAL STAFF APPLICATION CHECKLIST: SQE-MST … · 2018. 5. 17. · SQE-MST-002 1 of 16 Ap MEDICAL STAFF APPLICATION CHECKLIST: Thank you for requesting an application

SQE-MST-002 1 of 16

MEDICAL STAFF APPLICATION CHECKLIST Thank you for requesting an application for medical staff membership andor clinical

privileges at American University of Beirut Medical Center All forms must be completed and

returned with the application The Application should be printed and returned to our office

with the Privilege Sheet and with your original signatures

Application

( ) One Completed and signed Application Form

( ) One updated Curriculum Vitae

( ) one form of identification that includes your name picture and signature (ie passport

copy) or Lebanese Identification Card) plus a wallet size current photograph

( ) List of CMErsquos for past two (2) years (Current CME not required if you have completed

residency or fellowship training or obtained board certification within the last two years)

( ) Completed and signed Clinical Privilege Form(s)

( ) Code of Ethics (to be retained by physician)

( ) Guidelines on Conflict of Interest

Insurance

( ) List of all previous Professional Liability Insurance Verification with claims filed settled or

pending)

LicensesCertification

( ) Copy of current Lebanese Order of Physicians registration

( ) Copy of Lebanese Ministry of Public Health license to practice Medicine or in a

specialtysub-specialty

( ) Copy of all previous Medical Licenses held in other countries

( ) Copy of National Social Security Fund participation registration

( ) Copy of Board Certification(s)

( ) Copy of BLSACLSPALSATLS current certification (if required)

Other Signatures

( ) Confidentiality of Information Statement

( ) Attestation Acknowledgement and Release form

( ) Disclosure of Conflict of Interest form

Documents required from applicant

( ) Copy of Medical Degree

( ) Copy of Residency(s) training certificate

( ) Copy of Fellowship(s) training certificate

( ) Letters of Recommendation (at least two letters should be provided from physicians who

are familiar with the applicantrsquos clinical practice(One letter should be from the

Chairperson or Chief of division of the last position that the applicant held and the other

letter should be from the program director of the Residency or Fellowship training)

Appendix 61 SQE-MST-002

SQE-MST-002 2 of 16

Application for Initial Appointment to the Medical Staff

TO Chairperson Department of ________________________________________

I wish to apply for appointment to

the

First Middle Last following category

___ Active ___ with admitting

___ Associate Medical Staff Membership ___ with consultation privileges to

AUBMC

___ Emeritus ___ without admitting

___ Honorary

Period of Faculty Appointment __________________________

The following are attached

Request of Clinical Privileges for the Specialty of _______________ Subspecialty of ____________

(if applicable)

A signed form for Disclosure of Activities which may involve Conflict of Interest

_____________________________________________

___________________________________

Applicant Signature Date

Chairpersons Recommendation

I agree with this applicantrsquos statement of health status

I recommend appointment to the following Category

___ Active ___ with admitting

___ Associate Medical Staff Membership ___ with consultation privileges to

AUBMC

___ Emeritus ___ without admitting

___ Honorary

I concur with the attached Clinical Privileges as requested on the form

I do not concur with the requested Privileges The reason(s) for changes have been discussed with

the applicant on _________________ and heshe understood and accepted (See changes on the

form)

I do not recommend appointment for the following reason(s)

___________________________________________________________________________________

_____________________________________ ______________

Chairperson Signature Date

Medical Board Action Date of Action________________________________

Approved as requested Approved with modification Not approved

Chief of Staff ____________________________________________ Date signed

________________________________ Signature

Appendix 62

SQE-MST-002

SQE-MST-002 3 of 16

Curriculum Vitae for Initial Appointment to the Medical

Staff

PERSONAL DATA

Full Name First Middle Last

Specialty

Subspecialty

Date of Birth

Day Month Year

Place of Birth

Residence Address

Street

City

Phone Cell Phone

Office Address

Street

City

Phone

EDUCATION (please include in CV)

Undergraduate

Graduate

Postgraduate Training

LICENSURE AND CERTIFICATION

Lebanese Licensure

Date of Lebanese Ministry of Health Licensure License No

Lebanese Order of Physicians registration number

Issue DateEnd Date

Has your License to practice Medicine in Lebanon ever been under any kind of investigation 1048576 Yes 1048576No

If yes please complete the following details

1- Date of Investigation Type of Investigation

Result of Investigation

2- Date of Investigation Type of Investigation

Result of Investigation

National Social Security Fund participation number Issue Date

Other Licenses

1- CountryState Status Issue DateEnd Date

Picture

Appendix 63

SQE-MST-002

SQE-MST-002 4 of 16

2- CountryState StatusIssue DateEnd Date

3- CountryState StatusIssue DateEnd Date

4- CountryState StatusIssue DateEnd Date

5- CountryState Status Issue DateEnd Date

SPECIALTY BOARD CERTIFICATION(S) (please include in CV)

APPOINTMENTS (please include in CV)

Hospital Appointments

Academic Appointments

SCIENTIFIC AND MEDICAL SOCEITY MEMBERSHIPS

Please include in CV

CARDIOPULMONARY RESUSCITATION (CPR) TRAINING ( as per the policy ldquoResuscitative training

3rd Edition SQE ndashMUL -001rdquo

Yes No

I have completed training in BLSACLS copy of certificate is attached

I am not trained in CPR but I am willing to enroll in training and I will

send a copy of certificate upon completion

I am unable to qualify for BLSACLS for the following reasons

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

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PREVIOUS AND CURRENT PROFESSIONAL LIABILITY INSURANCE

1- Name of Professional Liability Insurance Company helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Policy Number helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Amount of Coverage helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Expiration Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

2- Name of Professional Liability Insurance Company helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Policy Number helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Amount of Coverage helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Expiration Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

SQE-MST-002 5 of 16

General Policies

Attachment to Application for Medical Staff Appointment

1 Members of the Active Medical Staff are expected to utilize the AUBMC available diagnostic

and therapeutic facilities for the care of their patients The facilities at the AUBMC are under

constant upgrading and reassessment to maintain them at the highest possible level of proficiency

2 Members of the Active Medical Staff on full time appointment in the Faculty of Medicine shall restrict their professional practice to the AUBMC its Outpatient Department or other medical

care facility administered by the AUBMC as assigned by the Chairperson of the Department

and the Dean except for consultations

3 Members of the Active Medical Staff on clinical appointment in the Faculty of Medicine shall

be actively engaged in teachingresearchservice at the Medical Center as assigned by their

respective Departmental Chairperson for a minimum of 600 hoursyear (12 hoursweek) They shall be expected to maintain the AUBMC as the primary facility for their private patients

4 Members of the Active Medical Staff are expected to 51 Attend department meetings

52 Attend meetings of the Medical Staff

53 Serve on committees

5 The foregoing duties as well as the educational and other professional responsibilities of a

member of the Active Medical Staff are concomitants of the privileges of admitting patients to

the AUBMC The continuation of this privilege depends upon conscientious and verifiable carrying out of these responsibilities

6 Members of the Clinical Associate Medical Staff appointed as ldquoAssociatesrdquo in the Faculty of Medicine shall be expected to be actively engaged in teachingresearch at the Medical Center

as assigned by their respective Departmental Chairperson for a minimum of 200 hoursyear (4

hoursweek)

7 Corrective measures and disciplinary action may be taken for violation of the Bylaws and

Rules and Regulations An appeal mechanism safeguards the rights of the individual

8 If appointed to the Medical Staff I hereby pledge that I will abide by and support the Bylaws

Rules and Regulations of the Medical Staff of the Medical Center of the American University

of Beirut as amended from time to time and to abide by the above set of general policies

Name_____________________ Signature _____________ Date ____________ (Print)

SQE-MST-002 6 of 16

DISCLOSURE QUESTIONS

Are you now or have you ever been subject to (provide FULL details for positive answers on a

separate sheet) Please place a check mark on each line YES NO

1 Previously successful or currently pending limitation suspension revocation

voluntary or involuntary surrender of license or registration to practice in any

jurisdiction

2 Previously successful or currently pending limitation suspension revocation

voluntary or involuntary surrender of Drug Enforcement Administration (DEA)

registration or its equivalent

3 Limitation suspension probation revocation denial non-renewal voluntary or

involuntary surrender of employment appointment privileges or training at any

hospital or health care related institution

4 Withdrawal of your application for appointment reappointment or clinical

privileges or resignation from a medical staff before a potentially adverse decision was made by a hospitalrsquos or health care facilityrsquos governing board

5 Formal investigation corrective action or discipline by any hospital or health

care related institution for any reason including patient complaints

6 Pending professional malpractice claims or actions medical conduct proceedings

or licensing board actions in any jurisdiction

7 Any judgment settlement or findings of medical malpractice or any findings of

professional misconduct in any jurisdiction please complete the Professional

Liability Explanation Form)

8 Suspension sanction or other restriction in participation in any private Federal or

State insurance program (eg Medicare) or similar entities

9 Current police or agency investigation substantiated charges or convictions for

sexual harassment sexual abuse child abuse elder abuse findings pertinent to

violations of patientrsquos rights or other human rights violations

10 Criminal convictions pending criminal proceedings or arrests for felonies or

misdemeanors

11 Malpractice premium ldquoratingrdquo surcharge malpractice insurance cancellation

denial or non-renewal

12 Resignation withdrawal or termination of your position with a professional

association or health maintenance organization for reasons related to clinical

quality or patient care issues

13 Do you currently have any physical or mental condition that impairs or could impair

your ability to practice medicine

14 Do you currently habitually use drugs or alcohol or have a dependence on drugs or alcohol (or have you ever had such habitual use of or dependence on drugs or

alcohol) that impairs or could impair your ability to practice medicine

SQE-MST-002 7 of 16

PROFESSIONAL LIABILITY EXPLANATION FORM

This form must be completed if you answered ldquoyesrdquo to question 9 on page 13 of the Medical Staff Application

Form

Please complete this form for each pending or settled professional liability claim or lawsuit and any payment

made on behalf of applicant All questions must be answered completely If additional sheets are required please photocopy this page prior to completing Please provide us with a separate sheet for each malpractice claim or

lawsuit

Date of Alleged Incident helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Date Claim Made or Suit Filed helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Patient Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Location of Incident helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Your Relationship to Patient (Attending Practitioner Surgeon Assistant Surgeon Consultant etc)

helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Allegation helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Liability Carrier when Incident Occurred helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Additional Named Defendant(s) [if applicable] helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Status

1048576 Open ndash If open amount being sought$ helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

1048576 Closedndash If closed indicate method of closing 1048576Dismissal 1048576Settlement 1048576Judgement

Amount of Settlement of Judgment $helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Summary Summarize the circumstances giving rise to the matter If the matter involves patient care provide a narrative

describing your care and treatment of the patient If additional space is necessary attach adequate clinical detail

to allow proper evaluation by a committee of physicians Include (1) Condition and diagnosis at time of incident

(2) dates and description of treatment rendered (3) condition of patient subsequent to treatment and (4) other

relevant information Please print helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

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SQE-MST-002 8 of 16

Signature (stamped signatures are not accepted) Date

Printed Name

SQE-MST-002 9 of 16

Attestations Acknowledgements and Release form

I fully understand that any significant misstatement(s) or omissions from this application

constitute cause for denial of appointment or cause for termination of appointment even

after recruitment to the Medical Staff at AUBMC I am also waiving any right of action or other

means of redress The information submitted by me in this application is true to the best of my

knowledge and belief I am willing to appear for interviews in regard to my application I

understand and agree that I as the applicant have the burden of producing adequate

information for proper evaluation of my application

I acknowledge that I have received and read the Bylaws Rules and Regulations for the

medical staff at AUBMC the policies relevant to the application process and generally to

clinical practice at the Medical Center and agree to be bound by the terms thereof in all

matters relating to staff membership and clinical privileges

By applying for appointment or reappointment to medical staff at AUBMC I hereby authorize

the Medical Staff Office to obtain information concerning my professional competence

character ethics and health to support my application I also authorize the release of this

information within AUBMC and to any of its affiliated Medical Centers The Medical Center

may use this information for any lawful purpose it deems appropriate

I consent to inspection by AUBMC its Medical Staff and their representatives of all documents

that may be material to an evaluation of my qualifications and competence I release from

liability any and all individuals and organizations who provide information to AUBMC in good

faith and without malice concerning my professional competence background experience

ethics character utilization practice patterns health status and other qualifications for staff

appointment and clinical privileges and I consent to the release of such information

I acknowledge that I have the necessary credentials to request the attached privileges and

that I am mentally and physically capable of performing them To the best of my knowledge I

have no physical or behavioral conditions that have affected or may affect my ability to

perform the clinical privileges requested I hereby agree to undergo at any time upon request

a mental or physical examination satisfactory to AUBMC and if there is a mental or physical

impairment to provide evidence satisfactory to AUBMC that the impairment does not

interfere with my competence to provide care to patients

I pledge to maintain an ethical practice to provide for continuous care to my patients to

accept committee assignments to accept consultation and to participate in hospital

activities as assigned by the chairperson of the Department Specifically I pledge to abide by

the professional fees established by AUBMC not to receive from or pay another physician

I fully understand that the patient has the right to the confidentiality of hisher medical

information and that heshe has the right to approve or refuse the release of specific

information

I affirm that I am the person referred to in the foregoing application

Signature Date

Appendix 64 SQE-MST-002

SQE-MST-002 10 of 16

CODE OF ETHICS

Approved by the Medical Board on November 4 2003

The following principles should serve as a guide to ethical behavior for all Medical Staff

Medical Staff must recognize their responsibility not only to patients but also to society to

other medical and paramedical staff medical students and to themselves The following

principles are standards of conduct that define the essentials of honorable behavior for all

Medical Staff

1 - Medical Staff shall be dedicated to providing competent health care to all patients

with compassion and respect for human dignity

2 - Medical Staff shall deal honestly with patients and colleagues

3 - Medical Staff shall respect the rights of patients and of other Medical Staff

and shall safeguard patient confidences within the constraint of the law

4 - Medical Staff shall continue to study apply and advance scientific knowledge

make relevant information available to patients colleagues and to the public

obtain consultation and use the expertise of other Medical Staff when indicated

5 - Medical Staff shall respect the patientrsquos right to ask for a second opinion or the

transfer of his care to another physician

6 - Medical Staff who deem it necessary to transfer the care of a particular

patient to another Medical Staff member

A - The request shall be made to the Medical Staff member In case of

conflict it should be referred to division or department head

B - The Medical Staff member shall continue to provide the patient with

competent health care until such time as the patientrsquos care is transferred

to another Medical Staff member

7 - Medical Staff shall recognize that patients are best served by continuity of

health care and shall promote the coordination of care with other Medical teams

involved in the patientrsquos treatment

8 - Medical Staff shall not take financial advantage of patients and shall

adhere to the internal rules of professional fees

9 - Medical Staff shall recognize a responsibility to participate in activities

contributing to an improved community

10- Medical Staff shall abide by the University Policy on ldquoDuality or Conflict of Interestrdquo

11 - Medical Staff shall abide by the Lebanese Order of Physicians and the

Ministry of Health Codes on ethical behavior

Appendix 65

SQE-MST-002

SQE-MST-002 11 of 16

Appendix 66

SQE-MST-002

SQE-MST-002 12 of 16

SQE-MST-002 13 of 16

SQE-MST-002 14 of 16

SQE-MST-002 15 of 16

Appendix 67

SQE-MST-002

SQE-MST-002 16 of 16

CONFIDENTIALITY OF INFORMATION STATEMENT

I the undersigned do hereby declare and acknowledge that in connection

with and during my employment work training at the American University of

Beirut and its Medical Center (AUBAUBMC) I may have access to certain

information data materials documents and records in various forms written

verbal and computerized or otherwise (jointly referred to as the confidential

information) related to patient care research and financial data at AUBMC

As an employee of AUBMC it is my responsibility to maintain the confidentiality

of all such information

Additionally I understand that accessing patientsrsquo medical information stored

either in hard copies or in electronic form (Electronic health records include

but not limited to radiology laboratory other results medications and clinical

notes) is limited to my scope of work at AUBMC on the principle of need-to-

know basis

I understand that an audit trail noting my access to any of the above

information may be conducted and if Irsquom found to be in violation then

disciplinary action may be taken by the AUBAUBMC

I also declare and acknowledge that any violation of the foregoing will cause

AUBAUBMC immediate and irreparable harm that money cannot adequately

remedy and that AUBAUBMC shall be entitled to terminate my employment

work training in addition to obtaining any other remedies available at law

After my employment work training at AUBAUBMC regardless of the reason

for leaving I agree and undertake to abide by all AUBAUBMC confidentiality

rules and procedures and I will preserve and maintain all the information in

strict confidence and will not use disclose or in any other way divulge the

information except when authorized by AUBAUBMC

Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Appendix 68

SQE-MST-002