Mercy Hospital Medical Staff Credentialing Manual - Mercy Health

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CREDENTIALING MANUAL REVISED AND APPROVED BY THE BOARD OF DIRECTORS JANUARY 24, 20082.1.1.11.Information about each voluntary and involuntary withdrawalfrom a medical staff or a voluntary or involuntary withdrawal ofan application for a medical staff appointment or ClinicalPrivileges; at any other hospital, health maintenance organization,health care entity or academic institution;2.1.1.12.Information about each pending or final suspension, revocationor restriction, or the voluntary or involuntary relinquishment ofan applicant’s:2.1.1.12.1.license to practice in any state;2.1.1.12.2.specialty board certification;2.1.1.12.3.state or federal narcotics registration certificate;2.1.1.12.4.ability to participate in any Federal Health Program;2.1.1.13.All professional malpractice claim information relative to theapplicant within the last ten (10) years2.1.1.14.Information about health status;2.1.1.15.Consent to submit to such physical or mental examination as theMEC may require. Taking or passing a physical or mentalexamination must not be a part of the application process, but theexercise of Clinical Privileges that are otherwise granted may bemade subject to the successful completion of such anexamination. The identity of the examining physician(s) must beby mutual consent. In the event of a disagreement concerning theneed for an examination or the identity of the examiningphysician(s), the matter must be referred to the Board, whosedecision on the matter is final;2.1.1.16.Consent to release of information from, and releases fromliability in favor of, insurance carriers, references, all institutionswhere applicant has worked, trained or practiced and to which hehas applied and all other sources of information required in theapplication, and consent to appear for an interview, if requested;2.1.1.17.Statement acknowledging and understanding MercyConfidentiality policy;2.1.1.18.A Medicare fraud attestation;2.1.1.19. The initial applicant shall submit four (4) passport sizephotographs which will be attached to the release executed by theapplicant and distributed to references to confirm the applicant’sidentity;2
CREDENTIALING MANUAL REVISED AND APPROVED BY THE BOARD OF DIRECTORS JANUARY 24, 20082.1.1.20.Verification that the applicant has received and reviewed theBylaws, Rules and Regulations and all policies of the MedicalStaff and of the Hospital relating to appointment to the MedicalStaff and the delineation of Clinical Privileges and that he agreesto be bound by them;2.1.1.21.A non-refundable application fee.2.1.1.22.Statement of Physician Expectations whereby the practitionerattests to having read and agrees to abide by the Expectations.2.1.1.23. Mercy Health supplemental forms, attestation, release and otherrelated documents.2.1.2. Applications for Reappointment: At least six months prior to theexpiration of a Member’s Medical Staff appointment, the CCO will sendthe Member a written reappointment form. The applicant must provide inhis reapplication, at a minimum, the following information or documents:2.1.2.1. Verification that all information provided on previousapplications remains correct, or updated information as necessary.The form must specifically seek, at a minimum, previouslyundisclosed information relating to:2.1.2.1.1.previously successful or currently pending challenges to anylicensure or registration or the voluntary relinquishment of suchlicensure or registration;2.1.2.1.2.voluntary or involuntary termination of medical staffmembership or voluntary or involuntary limitation, reduction orloss of clinical privileges at another hospital;2.1.2.1.3.Any evidence of an unusual pattern of an excessive number ofprofessional liability actions resulting in a final judgment againstthe applicant; involvement in each professional liability action,including all judgments and settlements within the past ten (10)years.2.1.2.1.4.relevant practitioner-specific data are compared to aggregatedata, when available; Performance Measurement Data includingmorbidity and mortality data when available; and2.1.2.2.Information about health status,2.1.2.3.Specific request for delineated Privileges,2.1.2.4. Sufficient clinical performance information to grant, limit or denythe requested privileges.3
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Mercy Hospital Medical Staff Credentialing Manual - Mercy Health

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