MEDICAL STAFF INITIAL APPLICATION CHECKLIST Incomplete applications will not be processed. Forms must be completely filled out, signed and dated Date of signature must be within 30 days of receipt of the application by the CVO □ 1. Call the CVO (614-546-3540) or email [email protected] to request the clinical privilege form □ 2. Non-refundable Application Fee; payable to Mount Carmel Health System (Grove City/East = one medical staff) □ One medical staff $500 □ Two medical staffs $800 □ Three medical staffs $1000 □ 3. Completed CAQH application must be on file with CAQH and attestation current within the past 120 days (A handwritten CAQH or a CAQH Data Summary is not acceptable as an application) □ 4. Board Certification required. If not currently certified, must attain Board Certification within 5 years of completion of Residency or Fellowship. □ 5. Application Addendum o Alternate provider identified o Program Director or Department Chair identified as a professional reference □ 6. Release of Information / Statement of Applicant □ 7. Confidentiality and Network Access Agreement □ 8. Disclosure/ Conflict of Interest Statement □ 9. Medicare Acknowledgement Statement □ 10. Application for System Access □ 11. New Privilege Applicant Letter o FPPE Evaluator identified □ 12. Curriculum Vitae/Resume; including work history; gaps of 28 days or more must be explained in writing □ 13. Professional Liability Insurance face sheet; must be rated A- or better by A.M. Best (must list effective and expiration dates, applicant's name, coverage minimums of $1M/$3M) o Past 10 years must be identified on CAQH or on a separate document □ 14. DEA Certificate □ 15. ACLS, BLS, ATLS, NRP, etc.; if applicable for privileges requested NOTE: ACLS and BLS must be American Heart Association courses □ 16. Electronic Fetal Monitoring (EFM) NCC certification (required for , with OB privileges) □ 17. Photo ID (Government issued) - must be legible (faxed copies are not legible) o Must present for ID verification prior to completion of credentialing □ 18. Additional documentation may be required based on your specialty and/or clinical privileges (Note: case logs are required for Level 2 and Level 3 privileges)

Please keep a copy of the documents submitted for your records Return all documents to: Mount Carmel Health System ▪ Credentialing Verification Office 6150 East Broad Street ▪ Columbus, OH 43213

APPLICATION ADDENDUM

All sections must be completed. Mark N/A if a section does not apply. Applications will be considered incomplete if sections are not fully completed. Incomplete applications will delay processing.

GENERAL INFORMATION

Applicant Name: ______Last First MI Degree

Current Home Address: ______Street City State Zip Country

Name of group/practice you are joining: ______

Partners or associates: ______

CAQH Provider ID#:______Date of Birth: ______SS#:______

Cell Phone #:______Preferred Email: ______

Citizenship: ______

Visa type: ______Effective date: ______Expiration date: ______

Military Service: Yes _____ No _____ Dates: ______If discharged, please provide a copy of your DD214.

Credentialing Contact Name: ______Phone:______(if different than applicant)

Fax: ______Email: ______

CATEGORY REQUESTED Check (√) the medical staff and category in which you wish to apply

Active Courtesy Coverage Consulting Community House Allied Locum Telemedicine Based Physician Health Tenens

(contracted) (Mid-Level Back Up coverage May not admit No clinical Provider) May Admit May Admit for a physician w/ patients privileges May not admit Patients Patients privileges. patients

Clinical No > 50 pts / 2 <50 pts / 2 May only admit Privileges and Clinical admitting years years under the name of Consults only Privileges only privileges physician being covered Gove City/East

St. Ann