Physician Employed Personnel (PEP) Initial Application

PHYSICIAN EMPLOYED PERSONNEL INITIAL APPLICATION

NAME

LAST FIRST M.I.

□ □

□ VIDANT BEAUFORT HOSPITAL □ VIDANT EDGECOMBE HOSPITAL

□ VIDANT BERTIE HOSPITAL □

□ □ VIDANT ROANOKE CHOWAN

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Physician Employed Personnel (PEP) Initial Application

Physician Employed Applicant Information □ Initial Appointment Please check appropriate category: □ RN □ LPN □ Dental Assistant □ Surgical Assistant □ Office Assistant □ Researcher □ Medical Physicist □ Lithotripsy □ Radiology Coordinator □ Other: ______

Please specify the Department you will be working in: ______

Please provide estimated percent of time spent at above designated Vidant Health entity:______(10%, 50%, 90%, etc.) ______

New Applicant’s Full Legal Name: ______

Applicant’s Social Security #: ______/_____/______Date of Birth ______

Home Address: ______(Street) ______(City) (State) (Zip)

Telephone #: ______Email: ______

Employer and Sponsoring Physician Information

Employer Practice/Group Name: ______

Sponsoring Physician from Practice/Group: ______

Employer Address: ______(Street) ______(City) (State) (Zip) Office Telephone #: ______Fax #: ______

Office Manager: ______Manager’s Direct Telephone #: ______

Manager’s email: ______

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Physician Employed Personnel (PEP) Initial Application

Licenses and Certifications (Please attach copy)

Name: ______# ______Date Issued: ______Exp: ______

Name: ______# ______Date Issued: ______Exp: ______

1) Have you ever been convicted of a criminal offense? □ No □ Yes If yes, list offense, conviction date, and whether a misdemeanor or felony.

2) Has your license to practice in any jurisdiction, been suspended, limited, restricted, reduced, revoked, denied or not renewed within the last year? □ No □ Yes □ NA If yes, please provide and explanation and attach to this application.

3) Have you been placed on probationary status or been reprimanded or cautioned by a state licensing or regulatory agency within the last year? □ No □ Yes □ NA If yes, please provide and explanation and attach to this application

4) Are there any challenges to your licensure or registration currently pending? □ No □ Yes □ NA If yes, please provide and explanation and attach to this application.

5) Have you voluntarily or involuntarily surrendered a license, registration, membership, at any institution within the last year? □ No □ Yes □ NA If yes, please provide and explanation and attach to this application.

EDUCATION: Please note that documented verification of education and training may be requested.

College(s) or Tech(s): Degree(s) Obtained: Years Attended:

______

PREVIOUS WORK EXPERIENCE (include training background and/or informal on-the-job training by physicians):

______

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Physician Employed Personnel (PEP) Initial Application

List PEP job description/duties/responsibilities in full detail below: May attach Job description for PEP role ______

List VIDANT supervising physicians – Vidant Health Medical Staff ______

PLEASE SUBMIT COPIES OF ITEMS LISTED BELOW • Liability Insurance • Licenses/Certifications (including current BLS/ACLS card if required) • Immunization documentation including Flu shot (seasonal), 2-step PPD (2 reads within past 12 months). Other Immunization documentation that could be included: Varicella, Tdap, MMR 1&2 • Background check attestation letter • Specific Competency Validation Form (if applicable) • Waiver Responsibility Form • Confidentiality Form • Code of Conduct Form • 11 Learn module certificates (print out with name) • Other documentation as requested

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Physician Employed Personnel (PEP) Initial Application

READ CAREFULLY BEFORE SIGNING Physician Employed Applicant (PEP) In completing this application, I attest that I have no known health conditions that would interfere with my work. I agree to abide by all Policies and Procedures that apply as if I was an employee of Vidant Health. I am expected to abide by a high standard of ethical behavior at all times. I agree to obey the laws and rules that apply to Vidant Health’s operation and to my particular duties. I will abide by the organization’s compliance program/Code of Conduct and understand that I have a duty to report potential violations to the compliance officer. I commit to supporting Vidant Health’s mission: To improve the health and well-being of Eastern North Carolina. I certify that the statements herein are made truthfully without evasion and agree that the statements may be investigated and if found materially inconsistent my request may be denied. I consent to verification of the credentials cited in this application and authorize the release of such information from the institutions. A copy of this statement shall be as binding as the original.

______Applicant Signature Requesting PEP Access Date

Sponsoring Physician Statement

This is to certify that the employee completing this application is under my supervision, and I assume responsibility for his/her work. I have received and agree to follow the Policies and Procedures regarding Physician Employee Personnel and agree that the above mentioned employee is qualified and competent to perform the scope of practice/privileges he/she is requesting.

I assure that if this employee does not have liability insurance that I as her supervising physician will make provisions for such liability insurance coverage while the employee is providing services at Vidant Health and that this information is updated annually. I will notify you promptly of the employee’s termination as my employee or supervisee.

______Sponsoring Physician Signature Date

______Sponsoring Physician Print Name

Approval or Denial - This portion is for Official Use Only

Approved: □ No □ Yes Denied: □ No □ Yes

Vidant Health Designee: ______Date: ______(signature)

Vidant Health Designee: ______(print name) Page 5 of 5