Physician application

Glendale Adventist

Medical Center 1509 Wilson Terrace Glendale, CA 91206

818-409-8010

Dear Doctor:

Thank you for your interest in Glendale Adventist Medical Center. Enclosed please find the application, privilege form, Bylaws, Rules & Regulations. Please be informed that the credentialing process can take 45 – 90 days to complete and listing current email addresses and fax numbers will assist with processing your application. The application must then be submitted to the Credentials Committee, the department to which you are applying, and have final approval from the Medical Executive Committee and the Governing Board. Application fee in the amount of $500.00 (non-refundable) payable to Glendale Adventist Medical Staff. Completed and signed Glendale Adventist Medical Center’s application. Curriculum Vitae Activity from residency/fellowship or the facility where you are actively practicing (document current competency) Delineation of Privileges form (please complete and sign). Please note: If you are requesting any advanced privileges

please submit documentation of training and current clinical competence. Acknowledgement Forms Confidentiality Agreement Coverage Agreement Medical Records Attestation form Disclosure/ Authorization and Release of Information Forms COPIES OF THE FOLLOWING Copy of current California license (wallet size); DEA registration, and professional liability coverage Please submit copies of the certificates from your previous malpractice carriers (last 10 years) Copy of current Radiologic Supervisor’s license, Fluoroscopy/Radiography/Dermatology Permits Copy of ECFMG certificate (if foreign medical graduate) Continuing Medical Education – List of activities for the last two years TB test results Documentation of influenza vaccination Please note you must be board certified or eligible at the time you submit this application. Please contact Tracy Joyce ([email protected]) in Medical Staff Services at 818-409-8451 with any questions you may have. Sincerely, Olivia Loeffler, CPMSM, CPCS Director, Medical Staff Services Enclosures Rev 0201

Page 2 GAMC Medical Staff Application

GAMC Application for Appointment to the Medical Staff

GLENDALE ADVENTIST MEDICAL CENTER

APPLICATION FOR APPOINTMENT AND CLINICAL PRIVILEGES TO THE

MEDICAL STAFF

GENERAL INSTRUCTIONS

Complete the application in full. Type or legibly print responses. Attach additional sheets if there is insufficient space on this form to complete your responses. Submit the completed, signed application to the Medical Staff Department at GAMC. Account for all time periods from medical school forward and attach a current CV, including bibliography.

PERSONAL INFORMATION

Name ___ ___ ____________________________ ___ Last First Middle Degree Cell phone/pager Birthdate Birthplace CA Driver’s License Number Social Security Number Primary Office ___ ________________________________________________ _____________ Number and Street Suite _ _______________________________________ City, State Zip Code Telephone Fax Secondary Office _________________________________________________________________________________________ Number and Street Suite _________________________________________________________________________________________ City. State Zip Code Telephone Fax Home Address___ _____________________________________________________________________ Number and Street __ _____________________________________ _____________________________________ City, State Zip Code Telephone Email address Marital (optional)

Status Married Single Widowed Divorced Name of Spouse: _____________________________ Foreign Languages Spoken ________________________________________________________________________________________

PHOTO-

Taped or stapled only,

no glue



Citizenship _____________________________________________________________________________________ (If not a citizen of the USA, please indicate status of visa at the present time.) Practice Limited to Specialty Practice NAME Name of Practice Office Manager Telephone/Extension #

Type of Practice Solo Group Other

EDUCATION

Undergraduate ___________________________________________________________________________________ Name of School Degree(s) Awarded From -To- Dates ____________________________________________________________________________________ Address (email address of fax preferred) City, State Zip Code Medical ____________________________________________________________________________________ School Name of School Degree(s) Awarded From -To- Dates ____________________________________________________________________________________ Address (email address of fax preferred) City, State Zip Code Other ____________________________________________________________________________________ Graduate Name of School Degree(s) Awarded From -To- Dates ____________________________________________________________________________________ Address (email address of fax preferred) City, State Zip Code

POST GRADUATE

Internships ____________________________________________________________________________________ Name of Facility Type/Specialty From -To- Dates ____________________________________________________________________________________ Address (email address of fax preferred) City, State Zip Code Program Director

____________________________________________________________________________________ Name of Facility Type/Specialty From -To- Dates ____________________________________________________________________________________ Address City, State Zip Code Program Director Residencies ___________________________________________________________________________________ Name of Facility Specialty From -To- Dates ____________________________________________________________________________________



Address (email address of fax preferred) City, State Zip Code Program Director

____________________________________________________________________________________ Name of Facility Specialty From -To- Dates ____________________________________________________________________________________ Address (email address of fax preferred) City, State Zip Code Program Director Fellowships/ ___________________________________________________________________________________ Preceptorships Name of Facility Specialty From -To- Dates ____________________________________________________________________________________ Address (email address of fax preferred) City, State Zip Code Program Director

___________________________________________________________________________________ Name of Facility Specialty From -To- Dates ____________________________________________________________________________________ Address (email address of fax preferred) City, State Zip Code Program Director

PROFESSIONAL AFFILIATIONS

Current Practice/Employment Affiliation ___________________________________________________________________________________ Name of Practice/Employment Type of Affiliation (i.e., Solo, Group, Partnership, etc) Director’s

Name

___________________________________________________________________________________ Address From -To- Dates Telephone Fax

___________________________________________________________________________________ Name of Practice/Employment Type of Affiliation (i.e., Solo, Group, Partnership, etc) Director’s

Name

___________________________________________________________________________________ Address From -To- Dates Telephone Fax Previous Practice/ Employment Affiliation

___________________________________________________________________________________ Name of Practice/Employment Type of Affiliation (i.e., Solo, Group, Partnership, etc) Directors Name

___________________________________________________________________________________

Address From -To- Dates Telephone Fax ___________________________________________________________________________________

Name of Practice/Employment Type of Affiliation (i.e., Solo, Group, Partnership, etc) Directors Name

___________________________________________________________________________________ Address From -To- Dates Telephone Fax



Hospital (List all current and previous hospital affiliations starting with most current.) Affiliations

_____________________________________________________________________________________ Name of Facility Staff Category From-To Dates _____________________________________________________________________________________ Fax or Email ; Address _____________________________________________________________________________________ Name of Facility Staff Category From-To Dates _____________________________________________________________________________________ Fax or email; Address

_____________________________________________________________________________________ Name of Facility Staff Category From-To Dates _____________________________________________________________________________________ Fax or email Address Academic Affiliations _____________________________________________________________________________________ Name of School Position From-To Dates _____________________________________________________________________________________ Number and Street City, State Zip Code

MEDICAL REFERENCES

List three (3) peers who have personal knowledge of your professional practice, current clinical abilities, ethical character, health status, and ability to work with others (preferably of same specialty/subspecialty). Only one reference may be from an associate/partner. Please DO NOT list your residency/fellowship director as a peer reference. A separate form will be sent to program directors automatically. Thank you. Name_______________________________________________________________________________________ Specialty Address_____________________________________________________________________________________ Telephone Fax Name_______________________________________________________________________________________ Specialty Address_____________________________________________________________________________________ Telephone Fax Name_______________________________________________________________________________________ Specialty Address_____________________________________________________________________________________ Telephone Fax



LICENSING

California State Medical License # ____________________________ Expiration Date _______________________ DEA Registration # ________________________________________ Expiration Date _______________________ Other State Medical Licenses ________________________________ _____________________________________

State License # Exp. Date State License # Exp. Date

ECFMG Number UPIN Number NPI Number Federal Tax ID Number

For informational purposes only: Do you accept Medicare in your office? Yes No Do you accept MediCal in your office? Yes No

BOARD CERTIFICATION

Board 1Name ________________________________________________________ Date ________ Expiration _______

Re-certified ? Yes No N/A Board 2 Name________________________________________________________ Date ________ Expiration _______ Re-certified ? Yes No N/A Subspecialty Certificate_________________________________________________ Date ________ Expiration _______

Re-certified ? Yes No N/A Subspecialty Certificate_________________________________________________ Date ________ Expiration _______

Re-certified ? Yes No N/A How many times have you set for the exam? _________ *Have you failed any part of the exam? Yes No If yes, how many times? _________. *If you have failed any part of the exam, please provide a written explanation on a separate sheet of paper. If not board certified: Are you qualified to sit for Boards? Yes No Have you made application to take Boards? *Yes No If yes, date taken *If yes, please provide a copy of the letter sent to you from the Certifying Board.

PROFESSIONAL LIABILITY

Present Carrier ___________________________________________________________Start Date_________________ Level of Coverage_____M/_____M Policy # ___________________________________ Expiration Date ____________ (Medical Staff Bylaws require minimum coverage of $1M/$3M.) *Name(s) of liability carriers for the past ten years if different from current carrier, include copies of all present and past insurance certificate(s): _______________________________________________________________________________________________ Name Policy # Start Date Expiration Date ________________________________________________________________________________________________ Name Policy # Start Date Expiration Date



If any of the following answers are affirmative, please provide a full explanation on a separate sheet of paper.

1. Have you been denied professional liability insurance, has your policy been cancelled, has your professional liability

carrier refused to renew your policy or placed limitations on the scope of your coverage, or has any professional liability carrier expressed intent to deny, or not renew or limit your professional liability insurance or its coverage, or is any such action pending?

Yes No 2. Have any professional liability claims been filed against you, have you reported any malpractice claim to your

professional liability carrier, or have you received any letters of intent to sue? Yes No

3. Have any judgments or settlements been made in any professional liability case in which you or your professional

liability carrier had to or agreed to make monetary payment, or is any such action pending? Yes No

CONTINUING MEDICAL EDUCATION

*ATTENTION: Attach an itemized list of all postgraduate activities that you have attended, or for which you have received Category I credit in the past two years.

HEALTH STATUS

If any of the following answers are negative, please provide a full explanation on a separate sheet of paper. 1. Are you able to perform all the procedures for which you have requested privileges with or without reasonable

accommodation, according to accepted standards of professional performance and without posing a direct threat to patients?

Yes No 2. Are you currently free from chemical dependency or substance abuse that could adversely affect your ability to

competently and safely perform the essential functions of a practitioner in your area of expertise? Yes No

DISCIPLINARY ACTION

If any of the following answers are affirmative, please provide a full explanation on a separate sheet. 1. Has your medical staff membership or privileges on any other medical staff been voluntarily or involuntarily

suspended, reduced, revoked, denied, or is such action pending? Yes No 2. Have you resigned or surrendered privileges while under investigation for questionable quality of patient care or

improper professional conduct or in return for such an investigation not being conducted, or is such action pending? Yes No

3. Has your license to practice medicine been suspended, limited, denied or revoked in the State of California or

any other jurisdiction, or is such action pending? Yes No 4. Has your DEA Registration been suspended, limited, denied or revoked, or is such action pending? Yes No



5. Have you voluntarily or involuntarily relinquished medical staff membership, clinical privileges, medical

organization or professional society membership, professional license(s), or narcotics registration, or is such action pending? Yes No

6. Have you been refused membership on a hospital medical staff or renewal thereof, or been subject to

disciplinary action, or is such action pending? Yes No 7. Have you been the subject of a proctoring or monitoring requirement at any hospital, whether or not such

request was imposed on you, or on a voluntary basis (other than at initial provisional appointment or for “New Procedures”), or is such action pending? Yes No

8. Have you been charged with or convicted of any drug or alcohol related offense? Yes No 9. Have felony criminal charges been brought against you?

Yes No

10. Have any Federal Government (i.e. MediCare, MediCal, VA, Champus) and/or Managed Care Organization imposed sanctions against you or is any such action pending? Yes No

The information contained in this application is complete, true, and correct to the best of my knowledge. I agree to report any change in my health status that would affect my ability to perform the privileges I have requested, and agree to submit to a health examination acceptable to the Medical Executive Committee should that committee consider it necessary. I further agree to promptly report any changes in my medical staff status with other healthcare organizations and any changes to my professional liability coverage and/or carrier to the Medical Staff of GAMC during the next two years. _________________________________ ___________________________________________________ Date Signature



CONFIDENTIALITY AGREEMENT FOR ONLINE SERVICES As a condition of, and in consideration for, gaining access to Patient Information through the Online Services (including, but not limited to, Project Intellicare, AHWebNet, and ConnectMD) of Adventist Health and its affiliated institutions (Adventist Health), I agree to this Confidentiality Agreement for Online Services.

I agree to comply with all applicable state and federal law (HIPAA) regarding access, use and disclosure of Patient Information and with all Adventist Health policies and procedures concerning the use of Patient Information and the Online Services. I agree to preserve all Patient Information, in whatever form, from loss, destruction, tampering and inappropriate access and use, including inappropriate disposal and forwarding.

I agree to access and use Patient Information (including protected health information and identity data) through the Online Services only in connection with my provision of health care-related services to individuals or to obtain payment for such services. I agree to limit my access to and use of Patient Information to what is reasonably necessary for these purposes. It is the policy and intent of Adventist Health to maintain and deliver Patient Information that is accurate, complete and timely. In some records, Adventist Health retains Patient Information created by other providers. I understand that I am solely responsible for whatever use I make of the Patient Information.

I understand and agree that I am responsible for my workforce (my office staff and others subject to my supervision) and their access to and use of Patient Information and the Online Services. I agree that such use and access by my workforce shall be consistent with the terms of this Agreement. I will not share my user ID or password with others, and I agree to obtain a unique identifier from Adventist Health for each member of my workforce who requires access to the Online Services and to notify Adventist Health in writing immediately (within at least 48 hours) of the termination of such person as a member of my workforce.

If I am authorized to sign documents by electronic/digital signature, I agree that I will not under any circumstances release my user identification code or password to anyone or allow anyone to access, authenticate or alter information using my identity. I understand that my electronic/digital signature is intended to be the legally binding equivalent of my handwritten signature.

I agree to adopt appropriate physical, technical and administrative safeguards to implement my obligations under this Agreement, including restricting access to and use of Patient Information and the Online Services, assuring proper password management, and implementing appropriate workforce discipline and termination procedures. I agree to implement such security features as Adventist Health may require to ensure the security of Patient Information and the Online Services and not to attempt to alter or reconfigure access rights or methods of access. I further agree to train members of my workforce having access to Patient Information and/or the Online Services, to monitor their compliance with applicable confidentiality and security requirements, and to take appropriate disciplinary action against violations. I agree to participate in HIPAA/confidentiality training should it be requested by Adventist Health.

I agree to immediately notify Adventist Health of any security breach or threat to the confidentiality or security of Patient Information or the Online Services of which I become aware, and of the actions I have taken or intend to take to mitigate the effects of such incidents. I understand that Adventist Health may utilize security software and other measures to monitor use of Online Services and compliance with this Agreement.

I agree to take such other actions as are necessary to carry out the purposes of this Agreement and will make my policies, procedures and other records relating to this Agreement available to Adventist Health for inspection upon request. I understand that Adventist Health may limit my access to Patient Information and the Online Services as necessary.

By: Date:

Signature

Print Name



GLENDALE ADVENTIST MEDICAL CENTER (“GAMC”)

RELEASE OF LIABILITY, ACKNOWLEDGEMENTS, AND AGREEMENTS I understand that the Medical Staff of GAMC (“Medical Staff”) is responsible for the evaluation and re-evaluation of my professional competence and qualifications, and has the obligation to inquire into my professional training, experience, professional conduct and judgment, and to make appropriate recommendations to the GAMC Governing Board. By submitting this application for membership and/or clinical privileges, I acknowledge that I have received and read the Bylaws, Rules & Regulations and Policies of the Medical Staff and that I am familiar with the principles of medical ethics of the American Medical Association, and I agree to be bound by the terms thereof in all matters relating to the consideration of my application, without regard to whether or not I am granted medical staff membership or clinical privileges. I further agree to be bound by the Bylaws, rules & Regulations and Policies of the Medical Staff. I pledge to maintain ethical practice and to provide for continuous coverage of all my patients. I agree that it is my duty and ethical responsibility as an individual physician and as an applicant or member of the Medical Staff, to cooperate with and assist the Medical Staff in evaluating not only my professional qualifications but also those of my colleagues. I agree to appear before Medical Staff officers and committees for interviews or inquiries pertaining to such matters at reasonable times and places. I hereby authorize and consent to the release of any information obtained or maintained by GAMC or its Medical Staff or their representatives to any organization where I provide, have provided, or have requested authorization to provide medical services. I further authorize and consent to the release of any information obtained or maintained by GAMC or its Medical Staff or their representatives concerning the status of my Medical Staff membership and clinical privileges, and the nature and extent of my clinical activity at GAMC to any accreditation organization. I hereby further authorize and consent to the communication and release to GAMC or its Medical Staff or their representatives of any information or documents for an evaluation of my professional training, experience, character, conduct and judgment which are maintained by/or are in the possession of any medical staff, hospital, medical school, training program, medical society, professional association, professional liability insurance company or licensing authority in any jurisdiction where I have trained, resided or practiced. I acknowledge that there shall be no monetary liability on the part of, and no cause of action for damages shall arise against, any employee, agent or representative of GAMC or its Medical Staff, for acts performed in connection with evaluating my application and my credentials and qualifications to the maximum extent provided by California or federal law. I further acknowledge that there shall be no monetary liability on the part of, and no cause of action for damages shall arise against, any individual and organization providing information to any employee, agent or representative of GAMC or its Medical Staff concerning my professional competence, ethics, character and other qualifications for staff appointment and clinical privileges to the maximum extent provided by California or federal law. I understand and agree that, as an applicant for medical staff membership, I have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics and other qualifications and for resolving any doubt about such qualifications. During such time as the application is being processed, I agree to update the application should there be any change in the information provided in the application. I hereby affirm that the information provided by me in my application to the Medical Staff and in connection with my application is true to the best of my knowledge and is provided in good faith. I understand that significant omissions or misrepresentations may result in denial, modification, or revocation of my medical staff membership and/or clinical privileges. I agree to report any changes in my health status that would affect my ability to practice medicine, and will agree to submit to a health examination acceptable to the Medical Executive Committee of GAMC should that committee consider it necessary. I, , do hereby make formal application for medical staff membership and clinical privileges at Glendale Adventist Medical Center. Date Signature of Applicant



SN DISCLOSURE and AUTHORIZATION TO OBTAIN INFORMATION

NS In connection with my suitability to apply for membership and/or privileges, appointment and/or reappointment at Glendale Adventist Medical Center, or during my appointment period, I understand that prior to or at any time after any approval of my application, a Consumer Report “initiated by the consumer,” may be requested from American Background Check Screening Services, Inc. (“American Background Check”), from public records including, but not limited to, my Social Security number, motor vehicle operation history/driving records, and criminal history to the extent permitted by law from various local, state, and federal agencies. I understand that this Report may include information as to my character, general reputation, personal characteristics, and mode of living, whichever are applicable.

I VOLUNTARILY AND KNOWINGLY AUTHORIZE ANY PRESENT OR PAST EMPLOYER OR SUPERVISOR, COLLEGE OR UNIVERSITY OR OTHER INSTITUTION OF LEARNING, ADMINISTRATOR, LAW ENFORCEMENT AGENCY, STATE AGENCY, LOCAL AGENCY, FEDERAL AGENCY, CREDIT BUREAU, COLLECTION AGENCY, PRIVATE BUSINESS, MILITARY BRANCH OR THE NATIONAL PERSONNEL RECORDS CENTER, PERSONAL REFERENCE, AND/OR OTHER PERSONS TO GIVE RECORDS OR INFORMATION THEY MAY HAVE CONCERNING MY CRIMINAL HISTORY, MOTOR VEHICLE HISTORY, SOCIAL SECURITY NUMBER, EARNINGS HISTORY, CHARACTER, AND EMPLOYMENT (INCLUDING REASONS FOR TERMINATION), CREDIT HISTORY, CREDIT CAPACITY, OR CREDIT STANDING OR ANY OTHER INFORMATION REQUESTED BY AMERICAN BACKGROUND CHECK DEEMED PERTINENT TO MY ASSOCIATION.

In accordance with the Fair Credit Reporting Act and state law, I understand that I have the right to request a complete and accurate disclosure of the nature and scope of the investigation requested. Further, I am entitled to know if an appointment is denied because of information obtained from American Background Check. If so, I will be so advised in writing and be given the name, address and toll free number of the agency, a statement that the action was based in whole or in part on information contained in the Report, and written notice that I have the right (i) if I request, to obtain within sixty days a free copy of the Report from the Reporting Agency (under no circumstances shall such cost exceed the actual costs of duplication), and from any other Consumer Reporting Agency which compiles and maintains files on consumers on a nationwide basis; and, (ii) to dispute the accuracy or completeness of any information in a consumer report furnished by the Reporting Agency. I understand that upon my request with reasonable notice and after furnishing proper identification, American Background Check’s trained personnel will provide me with investigative information in my file during normal business hours in person or upon written request, by certified mail to a specified addressee, or telephone as permitted by law. Further, I understand that should I wish to review my file in person, I am permitted to be accompanied by one other person of my choosing who shall furnish reasonable identification. I understand that American Background Check is a Consumer Reporting Agency and it is American Background Check’s policy to not be involved in or make decisions or recommendations regarding my appointment; however American Background Check will provide a written explanation of any coded information contained in my file. American Background Check’s privacy policy limits the information it provides to the Subscriber named herein, however I hereby authorize the Subscriber to share such information with parties in interest who have a “need to know” such information to protect them and their employees. Such information may include names and dates of other Subscriber inquiries to American Background Check. American Background Check does not sell or otherwise provide any of the information found in its background investigations to any other party. I understand that any Consumer Report or Investigative Consumer Report requested would be used strictly for permissible purposes under section 604(a)(f) for a general business purpose, which I initiated as defined under the Fair Credit Reporting Act. I understand to be considered, I must authorize the procurement of such Report(s). A photographic or faxed copy of this form shall be as valid as the original. *************************************************************************************************************************************** The following must be filled out completely and signed for your application to be consider (Please print)

LAST NAME ____________________________________FIRST NAME _________________________ MIDDLE NAME/INITIAL ____________ HOME ADDRESS _______________________________________________________________________________________________ CITY _________________________________________ COUNTY___________________ STATE _______________ ZIP ____________ ______________________________ ______________________________ ___________ _________________________________ SOCIAL SECURITY NUMBER DRIVER'S LICENSE NUMBER or STATE ID # STATE ISSUED E-MAIL ADDRESS FOR IDENTIFICATION PURPOSES, PLEASE PROVIDE: FULL DATE OF BIRTH ________________________________ HAVE YOU USED ANY NAMES OR SOCIAL SECURITY NUMBERS OTHER THAN ABOVE? Yes No Please List Other Names Used ________________________________________ Please List Other SS Number Used __________________

(Please sign) _____________________________________________________________________________ TODAY'S DATE ______________________

Signature Authorizing the Procurement of the Consumer Report and/or Investigative Consumer Report

I understand that in California, Minnesota, or Oklahoma if a Consumer Report/Investigative Consumer Report (including any Credit Report) was requested, I may order a copy of such report and it will be mailed to me: Yes, please send me a copy of my Report



RELEASE AND AUTHORIZATION In connection with my suitability to apply for membership and/or privileges, appointment and/or reappointment at Glendale Adventist Medical Center, or while providing services (herein “Hospital”), I understand that if the membership and/or privileges, appointment and/or reappointment which I am seeking or currently hold would require protection of “persons at risk” including, but not limited to working directly and in an unaccompanied setting with minor children, working with mentally disabled individuals, working with physically handicapped, the elderly, or others who could be considered at risk, or if I have supervision or disciplinary power over such persons, or if in the course of my hospital privileges I may come in contact or work in the proximity of such persons, in the sole discretion of the Hospital a search of the "State Sexual Offender Database" (registration of convicted sex offenders) will be conducted and the results reported to the Hospital.

I UNDERSTAND THAT THE HOSPITAL MAY USE THE INFORMATION OBTAINED FROM THE SEARCH DESCRIBED ABOVE FOR CREDENTIALING PURPOSES, INCLUDING, BUT NOT LIMITED TO, PRIVILEGES, MEMBERSHIP, APPOINTMENT/REAPPOINTMENT, EXCEPT THAT INFORMATION OBTAINED FROM THE SEXUAL OFFENDER IDENTIFICATION LINE WILL BE USED FOR THESE PURPOSES ONLY TO THE EXTENT THE HOSPITAL DETERMINES THERE IS A NEED TO PROTECT "PERSONS AT RISK," AS THAT TERM IS USED IN CALIFORNIA PENAL CODE SECTION 290.4(E)(1). I HEREBY KNOWINGLY AND VOLUNTARILY AUTHORIZE AMERICAN BACKGROUND CHECK TO SEEK THE INFORMATION DESCRIBED ABOVE ON BEHALF OF THE HOSPITAL AND AUTHORIZE THE HOSPITAL TO USE THAT INFORMATION (INCLUDING INFORMATION OBTAINED FROM THE SEXUAL OFFENDER IDENTIFICATION LINE) AS AUTHORIZED UNDER APPLICABLE LAWS. ADDITIONALLY, I HEREBY RELEASE ALL PARTIES AND PERSONS FROM ANY AND ALL LIABILITY FOR ANY DAMAGES, AND VOLUNTARILY WAIVE ANY AND ALL RIGHTS, CLAIMS, CHARGES, COMPLAINTS, OR CAUSES OF ACTION I HAVE OR MAY HAVE AGAINST THE HOSPITAL AND/OR AMERICAN BACKGROUND CHECK, INCLUDING ANY OF THEIR CLIENTS, EMPLOYEES, AND REPRESENTATIVES, AS A RESULT OF THE HOSPITAL’S AND/OR ITS REPRESENTATIVES ACTIONS IN SEEKING, USING, AND/OR DISCLOSING INFORMATION FROM THE SEX OFFENDER IDENTIFICATION LINE OR ANY OTHER SOURCE SOLELY AS IT RELATES TO THE CREDENTIALING PROCESS, MY PRIVILEGES, MEMBERSHIP, AND/OR MY APPOINTMENT/REAPPOINTMENT.

I further understand that any approval of hospital privileges, membership, appointment/reappointment will be conditional upon the receipt of satisfactory information as determined by the Hospital and that to be considered for privileges, membership, appointment/reappointment, I must authorize this release form. Further, I understand that I will be provided and must authorize a separate disclosure form as required under the Fair Credit Reporting Act and applicable state laws. A photographic or faxed copy of this Release and Authorization Form shall be as valid as the original.

The Report shall be provided by AMERICAN BACKGROUND CHECK

************************************************************************************************** The following must be filled out completely and signed for your application to be considered(Please print

LAST NAME ____________________________________FIRST NAME _________________ MIDDLE NAME/INITIAL ____________ HOME ADDRESS ______________________________________________________________________________________________________ CITY _______________________________ STATE _______________ ZIP _________________Email________________________________ ___________________________________________ ______________________________________ ________________________ SOCIAL SECURITY NUMBER DRIVER'S LICENSE NUMBER STATE ISSUED

(Please sign) ___________________________________________________________________________ TODAY'S DATE ________________________

Signature © 1998-2003 American Background Check All Rights Reserved (HOS7895)



Supplement to Application

MALPRACTICE DETAILS Please provide the following information for each new, dropped, still pending, or settled malpractice action (based on year of alleged incident).

ALL INFORMATION WILL BE HELD IN STRICT CONFIDENCE Name:

Plaintiff(s): ______________________________________________ Your role in this event: ___Primary defendant ___Co-defendant ___ Other Date of Suit: __________________ Disposition of Case: ___Judgment in favor of ___defendant(s) ___plaintiff(s) ___Settlement ___Dismissal ___with prejudice ___without prejudice ___Pending/Open Date suit closed: __________________ Amount awarded: $_________________ Please provide a narrative summary of the allegations and your involvement in the litigation:

___________________________________________________________________________ ___________________________________________________________________________ Date: Signature:

*If more than one action exists, please photocopy this page and submit information for each case.



COVERAGE AGREEMENT LETTER Please provide verification of your coverage for patients in accordance with the Medical Staff Rules & Regulations (page 6 section 10): “All medical staff members will provide coverage for their practice in their absence by another GAMC medical staff member with similar privileges. Each staff member or his covering physician shall maintain an adequate method of telephone contact. In case either the member or his covering practitioner fails to respond the hospital president, in consultation with the department chairman or chief of staff, shall have authority to call any member of the staff, should he consider it necessary. Failure to comply adequately with the provisions of this paragraph shall be cause for suspension of privileges by the Medical Executive Committee, until reinstated by the Medical Executive Committee.”

PLEASE SIGN BELOW: This agreement will be placed in your credentials file in accordance with TJC (MS.5.10.2.)

I agree to provide continuous coverage for my patients and will maintain an adequate method of telephone contact: Print Name: Signature: Specialty: Date: In addition, each medical staff member must alternate coverage for their patients in case of an emergency by another medical staff member of Glendale Adventist Medical Center, who holds similar privileges. Please indicate your alternate(s) names including the alternate’s signature on the lines below prior to returning the letter to the Medical Staff Office via mail or fax (818) 546-5632. ALTERNATE PHYSICIAN #1 ALTERNATE PHYSICIAN #2 Name Specialty Name Specialty Thank you for your prompt attention to this request. Sincerely, Medical Staff Services



GLENDALE ADVENTIST MEDICAL CENTER PHARMACY SIGNATURE FORM

In accordance with JCAHO Standard IM.8 “The hospital collects and analyzes aggregate data to support patient care and operations (intent - section g) – practitioner specific information” and Hospital regulations; the Department of Pharmacy Services must have a means of identifying each Medical Staff Member’s signature, initials, DEA number and California License number. As an applicant, we ask that you provide the information requested below including your signature and initials in the designated spaces: PRINT NAME: _____________________________________________ SPECIALTY: _____________________________________________ ADDRESS: _____________________________________________ _____________________________________________ PHONE#, FAX# _____________________________________________ ID NUMBER: _____________________________________________ To be completed later DEA NUMBER: _____________________________________________ CA LICENSE NUMBER: _____________________________________________ SIGNATURE: _____________________________________________ INITIALS: _____________________________________________ DATE: _____________________________________________ Rev. 01/01 /tlj




MEDICAL RECORDS ATTESTATION FORM

In accordance with the Federal Register, HCFA published amendments to the Medicare regulations (vol. 49, no. 171), reimbursement is now based on DRGs, and physicians must be notified of the penalty that may be imposed for intentional misrepresentation of final diagnosis. In order to comply with this regulation, we are asking all physicians to sign and date the following penalty statement. The acknowledgement will be kept on file in Medical Records for inspection by government reviewers. Sincerely, Olivia Loeffler, CPMSM, CPCS Director, Medical Staff Services Notice to Physicians: Medicare payment to hospitals is based in part on each patient’s principal and secondary diagnosis and the major procedures performed on the patient, as attested to by the patients attending physician by virtue of his or her signature in the medical record. Anyone who misrepresents, falsifies or conceals essential information required for payment of Federal funds, may be subject to fines, imprisonment, or civil penalty under applicable Federal Laws. Print Name: Signature: Date:

PLEASE COMPLETE AND RETURN

Saved as Form - Attestation



GLENDALE ADVENTIST MEDICAL CENTER ACKNOWLEDGEMENT

OF HEALTH STATUS

&

RECEIPT OF:

Medical Staff Bylaws Medical Staff Rules & Regulations

General Medical Staff & Department Policies I do hereby acknowledge that I have received and read the Bylaws and Rules & Regulations of the Medical Staff, Medical Department Policies for my specialty and the General Medical Staff Policies and I agree to be bound by the terms thereof. I agree to report any changes in my health status that would affect my ability to practice medicine, and will agree to submit to a health examination acceptable to the medical staff of Glendale Adventist Medical Center should this be considered necessary. In accordance with Policy #4-680 Two Step TB Testing” (attached), I understand that as a new healthcare practitioner at GAMC I must document a negative PPD. I will contact the Employee Health Service at (818) 409-8160 to schedule an appointment.

Print Name: ________________________________________________ Signature: ________________________________________________ Date: ________________________________________________ Rev. 03/00

PLEASE SIGN, DATE & RETURN



Glendale Adventist Medical Center Medical Staff Peer Review Activity

Confidentiality Agreement I, _________________________________, a member of the Medical Staff who is involved in the evaluation and improvement of the quality of care rendered at Glendale Adventist Medical Center, (i.e., Department Chief; committee member; or an individual physician assisting in peer review activity), recognize that confidentiality is vital to the full and free discussions necessary to effective peer review activities. I therefore agree to respect and maintain the confidentiality of all discussions, deliberations, minutes, records, and other information generated in connection with these activities, and to make no voluntary disclosures of any such information except to persons authorized to receive such information in the course of conducting Medical Staff affairs. I understand that the Hospital and the Medical Staff are entitled to undertake such action as it deemed appropriate to ensure that confidentiality is maintained, including action necessitated by any breach or threatened breach of this agreement, including dismissal from my committee assignment or hospital staff. __________________________________ _______________ Signature Date __________________________________ Name, printed

TJC Participation Requirements – APR 17 The Mission of JC is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement.

If, after reporting viable concerns of quality of care or patient safety to your supervisor (chain of command), and the issue is unresolved, an employee, physician and allied health professional has the right to notify the JC without disciplinary actions taken against them. The TJC number is - 800.994.6610 or the website at [email protected].




TB ATTESTATION FORM

Tuberculosis control in a health care facility requires the effective detection of diseases and new infection as well as the prevention of transmission. Thus, in keeping with recognized standards of medical care, TB infection must be assessed in each employee, new hire, volunteer, and physicians before credentialing. CHECK OFF LIST

“I attest that I have been screened for TB infection by a two-step PPD skin test and had a negative PPD within the last 12 months. I am attaching the test results to this form.”

“I have not been screened for TB within the past 12 months and will call the GAMC Employee Health department at 818-409-8000, x8160 for a free screening. I agree to forward the test results to Medical Staff Services.”

“I have been screened for TB within the past 12 months, had a positive test result, followed by a negative chest x-ray, the test results of which I am attaching to this form;

Or, I need a chest x-ray and will call the GAMC Employee Health department at 818-409-8000, x8160 for a free screening. I agree to forward the test results to Medical Staff Services.”

Signature Date Print Name ORIGINAL: CREDENTIALING FILE CC: EMPLOYEE HEALTH



FLUOROSCOPY / RADIOGRAPHY / DERMATOLOGY PERMITS

Please complete this form and return it with your application. It is necessary that all applicants to the medical staff reply, regardless of use or non-use of x-radiation. A licentiate of the healing arts who wishes to use x-radiation in his/her parctice must hold a permit for fluoroscopy, radiography or dermatology supervisor or operator from the State of California Department of Health Services. It is unlawful to bill Medi-Cal for x-ray services performed by a person who does not hold the proper permit. If you intend to use x-radiation in your hospital practice, please forward a copy of your permit with your application. Please note that the permit is required for some specified privileges listed on the privilege forms.

I use x-radiation in my hospital practice and I have enclosed a copy of my permit.

I do not use x-radiation in my hospital practice.

I plan to use x-radiation in my hospital practice and will obtain a permit and forward a copy of the permit to Medical Staff Services.

Print Name: Signature: Date:

Attachment: A copy of Title 17, Group 5, Article 1, Sections 30460 – 30468 which explains the permit.

PLEASE COMPLETE, SIGN, DATE & RETURN



CODE OF CONDUCT

YOUR RESPONSIBILITIES

CORPORATE COMPLIANCE PROGRAM This program provides a standard for ethical behavior and a reporting system for notifying management of potential ethical breaches. The organization’s legal board adopted the formalized compliance program, which consists of written policies, procedures, and a code of conduct designed to prevent violations of applicable laws, regulations, policies and procedures. In addition it is designed to detect and correct violations, should they occur. You may find the entire compliance program on Adventist Health’s Roseville Connect Intranet page at: https://connect.ah.org/portal/site/admin under the Corporate Compliance Department “Compliance Program” folder or on Adventist Health’s web page under “About Us:” http://www.adventisthealth.com/aboutus/goDocDocument.asp?CN=3&DID=970.

Adventist Health is a highly regarded healthcare provider. Our reputation has been achieved through the dedication of individuals committed to quality, honesty and fairness. Each of us is responsible for continuing to protect and enhance that reputation for the future. The Adventist Health Code of Conduct is based on the biblical counsel to treat others as we would have them treat us. Great effort is taken to ensure that as officers, employees, contractors or volunteers of Adventist Health and its affiliates, we conduct ourselves with integrity in accordance with all applicable laws and ethical business standards. The material that follows is Adventist Health’s formalized Code of Conduct, which in turn is followed by a brief description of the Federal and State laws addressing false claims and whistleblower protections.

ADVENTIST HEALTH CORPORATE CODE OF CONDUCT

Mission

Adventist Health’s mission is to share God’s love by providing physical, mental, and spiritual healing Adventist Health (“AH”) and its Affiliates, in keeping with their mission, strive to conduct themselves in accordance with strong business ethics and in compliance with all applicable laws. This Code of Conduct is upheld through the integrity and ethical practices of our officers, employees, contractors, and agents. To maintain its standards in an increasingly regulated business environment, AH has established this formal Code of Conduct, which provides general guidelines on how AH and its Affiliates will conduct business. As such, this Code of Conduct governs the conduct of all employees and contractors of AH and its Affiliates. Knowledge of and adherence to these standards allows AH to continue serving its patients and communities in a professional, caring, and ethical manner. Compliance with Laws

AH policy requires AH and its Affiliates, officers, directors, employees, contractors, and agents to comply with all applicable laws, including Federal and State health care program requirements. Failure to do so exposes AH organizations’ officers, directors, employees, contractors, and agents to possible sanctions, monetary penalties, criminal prosecution and other disciplinary actions. When the application of a law is uncertain, AH or its Affiliates will seek appropriate guidance. Reporting of Violations

AH and its Affiliates support and encourage any officer, director, employee, contractor, or agent to maintain individual responsibility for monitoring and reporting any activity that appears to violate any applicable laws, rules, regulations, policies and procedures, or this Code of Conduct. In order to provide every avenue possible in which to raise their concerns, AH and its Affiliates have established a confidential reporting mechanism that includes anonymous reporting if the person making the report so desires. Using this mechanism does not, however, relieve an individual of his other obligation to utilize the organization’s grievance and arbitration procedures, if the matter is covered by such a procedure. Anyone who becomes aware of a violation of any laws, including Federal and State health care program requirements, company policies and procedures, the AH Corporate Compliance Program, or this Code of Conduct is expected to report the improper conduct. This reporting can be accomplished either verbally or in writing through a supervisor, the local compliance officer,

https://connect.ah.org/portal/site/admin

http://www.adventisthealth.com/aboutus/goDocDocument.asp?CN=3&DID=970



compliance report form, hotline, (888) 366-3833, or the AH Corporate Compliance Officer, (877) 336-3566. The local compliance officer, with assistance from the AH Corporate Compliance Department, will investigate all reports and ensure that proper follow-up actions are taken. AH policy prohibits any organization or individual from retaliating against a person who makes a complete and accurate report in good faith. It is the policy of AH and its Affiliates that employees shall not be punished for reporting what they reasonably believed to be an act of wrongdoing or a violation of the AH Corporate Compliance Program. However, an employee will be subject to disciplinary action if their employer reasonably concludes that the report of wrongdoing was knowingly fabricated by the employee or was knowingly distorted, exaggerated or minimized to either injure someone else or to protect or benefit the reporting employee. Conflicts of Interest

AH and its Affiliates require officers, directors, employees, contractors, and agents to exercise individual loyalty to AH in fulfilling their responsibilities. These individuals must avoid any situation where a conflict of interest exists or might appear to exist between their personal interests and those of AH or its Affiliates. The appearance of a conflict may be as serious as an actual conflict of interest. If a conflict of interest exists or appears to exist, the individual must follow the conflict of interest procedures adopted by the AH organization, a copy of which is available. Examples of Applicable Laws

Although it is not practical to list all laws, including Federal and State health care program requirements, to which AH and its Affiliates are subject, the following are examples of the more common laws subject to this Code of Conduct. Patient Admission and Transfer

Admission to an AH facility should be based strictly upon medical necessity. Only an appropriately licensed person should determine whether to admit a patient to an AH facility. AH management should ensure that facility personnel and medical staff members are never pressured to admit patients inappropriately and that patients are admitted only on the basis of medical need. A patient should not be transferred from an AH facility if such transfer threatens the patient’s health or is in violation of law. If applicable, each AH facility shall adopt patient transfer protocols. Payment for Referral

AH and its Affiliates do not offer, pay or receive payments in exchange for the referral of a patient or other business. AH and its Affiliates only pay people or entities for actual items or services provided to the organization or community. AH and its Affiliates do not offer or provide illegal benefits, whether cash or non-cash, to any physician or health professional. Accuracy in Billing

AH and its Affiliates are committed to prepare and submit accurate claims for medically necessary services rendered. All bills must be accurate and conform with federal and state laws and regulations. Marketing Activities

AH and its Affiliates must comply with all state and federal requirements regarding marketing. Political Activities

Although officers, directors, employees, contractors, and agents are encouraged to participate freely and actively in the political process, they should ensure that their political activities are lawful and separate from their activities as an employee or contractor of AH or an Affiliate. Personal political activities must not unreasonably interfere with the individual’s ability to perform his or her duties for the AH organization, and must be consistent with applicable laws, rules, regulations and the policies set forth in this Code of Conduct. Patient Rights Laws

AH and its Affiliates are committed to abiding by all applicable laws, rules and regulations regarding and protecting their patients’ rights, including confidentiality and other rights.


FEDERAL AND STATE FALSE CLAIMS ACTS

Federal and state false claims acts prohibit any person or entity from, among other things, knowingly presenting, or causing to be presented, a false or fraudulent claim for payment or approval, or knowingly making or using, or causing to made or used, a false record or statement to get a false or fraudulent claim paid or approved. The penalties for violating the federal or state false claims acts include:



Civil monetary penalties of up to $10,000 for each false claim submitted;

Three times the amount of damages which the government sustains because of the false claim; and

The costs of the legal action brought to recover for the false claim. A private citizen may file suit under the federal and state false claims acts on behalf of the government if the citizen has direct and independent knowledge of the submission of a false claim. The government will then decide whether to intervene and take over the case, dismiss or settle the case, or let the private individual pursue the case on his or her own. In either case, the person who initially filed the case may receive a portion of the amount recovered in either litigation or settlement of the claim. Your local compliance officer can provide more detailed information regarding the federal and state false claims acts.


WHISTLEBLOWER PROTECTIONS

Both the federal and state false claims acts prohibit employers from retaliating or discriminating against an employee who, acting in good faith, investigates, reports or assists in uncovering a false claim or statement. An employee who suffers discrimination or retaliation based on protected activities has the right to sue under the both the federal and state false claims acts. If the employee can prove that his or her employer retaliated against him or her for engaging in protected activity, the employee is entitled to be “made whole.” The remedies may include:

reinstatement of the employee to his or her position,

two times the amount of back pay,

interest on the back pay, and

compensation for any special damages (including litigation costs and reasonable attorneys’ fees). As noted above, it is the policy of Adventist Health and its affiliates that no employee shall be punished solely on the basis that he or she reported what he or she reasonably believed to be an act of wrongdoing or a violation of the Adventist Health Corporate Compliance Program.

YOUR LOCAL COMPLIANCE OFFICER CAN PROVIDE MORE DETAILED INFORMATION REGARDING THE PROTECTIONS AFFORDED EMPLOYEES UNDER THE FEDERAL AND STATE FALSE CLAIMS ACTS.

CODE OF CONDUCT

ACKNOWLEDGMENT OF RECEIPT AND REVIEW

I have received and read a copy of the Adventist Health Corporate Code of Conduct and agree to abide by the policies and rules contained therein. Adventist Health reserves the right to modify this Code at any time at its sole discretion. _______________________________ _____________________ Signature Date

PLEASE REVIEW, SIGN, DATE & RETURN

Updated: 04/08/08

Documents

Physician application