Proprietary and Confidential Copyright ECRI Institute, 2013 Martina Diditright, MD: CV Martina Diditright, MD 1001 Garden Drive Healthy Town, Good State, USA Ph: 000-123-456 Fax: 111-222-333 Email: [email protected]Education and Postgraduate Training: 7/ 1996-6/ 1999 Post Graduate Training Goodville Hospital, Greene City, Good State, USA; Goodville Hospital Family Practice Group, Greene City, Good State, USA. 7/ 1992-6/ 1996 University Medical College, Small State, USA 9/ 1988-5/ 1992 Urbanville College, Commonwealth of Urbanville, USA. BA (Chemistry) Board Certification : 1999 Family Medicine, 2009 recertification Family Medicine 2008 Emergency Medicine Other Certifications: ACLS current (expires 12/ 31/ 2013) Licensure: Good State, USA (license no. 991122, expires 12/ 31/ 2014) Commonwealth of Urbanville (licensure no. 007008, expires 08/ 31/ 2015) DEA AB12340 expires 7/ 31/ 16 Practice Experience: 03/ 2012-07/ 2013 Urbanville Hospital Family Practice Group (Urbanville, USA) 01/ 2011-12/ 2011 Wellness Hospital -- emergency department (Urbanville, USA)
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Martina Diditright, MD: CV · Martina Diditright, MD: CV Martina Diditright, MD 1001 Garden Drive Healthy Town, Good State, USA Ph: 000-123-456 Fax: 111-222-333 Email: [email protected]
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Goodville Hosp ital, Greene City, Good State, USA;
Goodville Hosp ital Family Practice Group, Greene City, Good State, USA.
7/ 1992-6/ 1996 University Medical College, Small State, USA
9/ 1988-5/ 1992 Urbanville College, Commonwealth of Urbanville, USA. BA (Chemistry)
Board Certification: 1999 Family Medicine, 2009 recertification Family Medicine
2008 Emergency Medicine
Other Certifications: ACLS current (expires 12/ 31/ 2013)
Licensure: Good State, USA (license no. 991122, expires 12/ 31/ 2014)
Commonwealth of Urbanville (licensure no. 007008, expires 08/ 31/ 2015)
DEA AB12340 expires 7/ 31/ 16
Practice Experience:
03/ 2012-07/ 2013 Urbanville Hospital Family Practice Group (Urbanville, USA)
01/ 2011-12/ 2011 Wellness Hospital --- emergency department (Urbanville, USA)
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07/ 2002-12/ 2010 Did itright Family Practice, Good State, USA.
07/ 1999-05/ 2002 Goodville Family Medical Center (Goodville, Good State)
Honors/Awards: Urbanville Volunteer Award (2011, 2012) (established annual free community
Health Fair)
Publications: ‘‘Improving Preventive Care for Patients w ith Low-health Literacy’’ Journal of Competent
Care 2012 May
‘‘Your Child ren’s Health’’ [weekly health column in The Goodville Press] 2009, 2010
‘‘How to u tilize quality measures to keep your patients out of the ED’’ Journal of Family
Medicine 2009 Dec
‘‘Managing chronic conditions through EHR tracking’’ Journal of Family Medicine 2009
Mar
‘‘How a potential lawsuit really affects your physician ’’ Journal of Law 2008 Oct
.
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Martina Diditright, MD: Application Packet
WELCOME LETTER FOR APPLICANTS
08/ 08/ 2013
Dear Dr. Did itright,
Thank you for your interest in becoming part of (name of health center) clinical staff. Prior to beginning your
service with (name of health center) you must complete our credentialing process and be approved by our board
of d irectors. The credentialing process involves evaluating a practitioner’s eligibility and competency for clinical
privileges. Our credentialing policy app lies to physicians, mid -level providers, and any licensed independent
healthcare practitioner who provides services in the (name of health center). All qualified applicants w ill receive
an application for medical staff membership and / or clinical privileges. We will make every effort to process your
application in a timely and efficient manner.
Credentialing is a five-step process:
Step 1. Applicant will receive the initial applicant packet
Step 2. Applicant will return completed applications along with requested documents
Step 3. Application will be reviewed and processed by our credentialing specialist to make sure all infor mation is
complete and accurate
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Step 4. The completed and verified applicant packet will be forwarded to the medical d irector to be presented to
the board of d irectors for approval
Step 5-. The Applicant will be notified of the board of d irectors’ decision
The credentialing process can take up to 90 to 120 d ays to verify, review, and obtain final app roval. To expedite
the process, your application should be without blanks or missing requested documents; if anything is missing,
the process will be delayed and could mean forfeiture of your privileges.
If at any time you have questions please contact ou r credentialing specialist at (phone number) or set up a
meeting to come to (name of health center) and go over your application prior to submission. Our goal is to assist
you to get on staff quickly while ensuring that we are compliant w ith Joint Commission and other relevant
guidelines.
Sincerely,
April Showers, MD
Medical Director
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CREDENTIALING APPLICATION
Please type or print responses legibly and in ink. Please complete the form in its entirety and attach all required
documentation. Incomplete applications will be returned to you and may result in a delay in the credentialing
process.
Supplementary d ocuments that must be completed and submitted include the following:
Affiliation Certification Letter
Three (3) Peer Reference Forms
Request for d elineation of Privileges
Professional Liability Claims History Form
Continu ing Medical Education (CME) Form
Attestation Statement
Please also submit the following with your app lication:
Curriculum vitae (CV)
Copy of medical/ professional license registration certificate
Copy of medical board certification
Other certificates (BLS, ACLS, ATLS, PALS, APLS)
Current Drug Enforcement Administration (DEA) registration
Current Controlled Dangerous Substances (CDS) registration
Copies of d iplomas (undergraduate, post-graduate, medical school, residency, fellowship)
Proof of professional liability insurance (policy declaration s page or letter from insurer)
Copy of most recent hepatitis B, MMR, and flu vaccination and tuberculosis PPD test
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Copy of government-issued picture identification
National Provider Identification number (NPI)
I. Demographic Information
Applicant Name: __Martina Did itright, MD______________________ SSN:123456789___________________ Address/ City/ State/ Zip:__1001 Garden Drive Healthy Town, Good State, USA _____________________ Phone: _000-123-456_________________Email: ____md id [email protected] ______Fax: _111-222-333_____ Date of Birth: _01/ 01/ 1965___ Place of Birth: Apple, USA__________________________________________ Gender: Male x Female Are you a United States Citizen? x Yes No If not a United States citizen, please check applicable box below: Work Permit (attach notarized copy) Visa Visa Type and Number: _________________
II. Professional/Licensure Information
Primary Practice Specialty:__Family Medicine_________________________________________Board Certified? x Yes No
Certifying Board:__American Board Family Medicine (1999, 2009), Emergency Medicine (2008)_______________________________
I, ____Martina Did itright, MD_________________________ (print full name of the physician/ practitioner), agree
as evidenced by my signature that the information provided in this application is true and complete to the best of
my knowledge and that the omission or falsification of information may be cause of ineligibility or terminatio n
from medical staff membership. I further agree that I have current professional liability coverage and I have
d isclosed the history of loss or limitation of privileges or d isciplinary action.
____ Martina Diditright MD ___________________8/15/2013_________________________
Applicant Signature Date
Martina Did itright, MD _________________________________________________________________ Print Name
All policies, procedures, and forms reprinted are intended not as models, but rather as samples submitted by ECRI Institute member and nonmember
institutions for illustration purposes only. ECRI Institute is not responsible for the content of any reprinted materials. Healthcare laws, standards, and
requirements change at a rapid pace, and thus, the sample policies may not meet current requirements. ECRI Institute urges all members to consult with
their legal counsel regarding the adequacy of policies, procedures, and forms.