Kaper 1 Form – Fill Out and Use This PDF

Commonwealth of Kentucky

Instructions - Form (04/2009), Part B, Section 1

A. Uniform Application for Evaluation (Credentialing) Form. Following is the form KAPER- 1 (04/2009), Part B, Section 1, developed pursuant to KRS 304.17A-535(5) for evaluation (credentialing) of a health care provider. The form is available on the Web site of the Kentucky Department of Insurance (http://insurance.ky.gov). Prior to completing this form, a health care provider who desires initial evaluation (credentialing) by a hospital or health care facility is advised to contact that specific hospital or health care facility for information regarding submission of the complete KAPER-1 (04/2009), Part B, Section 1, and required attachments, as applicable and specified in item C of this instruction.

B. Cover Letter. A cover letter, which is signed and dated by the health care provider who desires evaluation (credentialing) by a hospital or health care facility, requesting consideration of the complete KAPER-1 (04/2009) Part B, Section 1, and required attachments, as applicable and specified in item C of this instruction, may be required.

C. Required Attachments.

For a Physician, unless otherwise specified in this instruction, one (1) photocopy of each of the following supporting documents should be labeled and attached to the complete form KAPER-1 (04/2009), Part B, Section 1, in the following order:

1.Current medical, dental or professional license or evidence of licensure, as applicable (If medical, dental or other health care provider, including a psychologist, has applied for, but not received this license, a copy of the application for this license will be accepted until a copy of the license is available for submission.);

2.Current federal drug enforcement agency (DEA) certificate for each state of practice. (If medical, dental or other health care provider, including a psychologist, has applied for, but not received this number, a copy of the application for a DEA number will be accepted until the DEA number is available for submission.);

3.Current state substance registration certificate, if applicable. (If medical, dental or other health care provider, including a psychologist, has applied for but not received this certificate, a copy of the application for this certificate will be accepted until a copy of the state substance registration certificate is available for submission.);

4.Proof of current professional liability insurance, including name, inception and expiration dates and amount of coverage (If medical, dental or other health care provider, including a psychologist, has applied for but not received professional liability insurance, a photocopy of the application for professional liability insurance will be accepted until the proof of current professional liability insurance is available for submission.);

5.Board certification/eligibility verification information;

6.Curriculum vitae (All time periods from receipt of degree to present must be accounted for);

7.Current photograph;

8.Photo identification (ID). Additionally, photo ID should be presented in person at the hospital or health care organization where participation is desired; and

9.Separate pages or supplemental forms, if any, in page number order.

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For an Allied Health Professional, unless otherwise specified in this instruction, one (1) photocopy of each of the following supporting documents should be labeled and attached to the complete form KAPER-1 (04/2009), Part B, Section 1, in the following order:

1.Current professional license or evidence of licensure (If multiple professional licenses are held by the allied health professional, a copy of each license and/or registration should be attached; for example, registered nurse (RN);

2.Current federal drug enforcement agency (DEA) certificate, if applicable for allied health professional specialty (If allied health professional has applied for but not been issued a DEA number, a copy of the application requesting this number may be submitted until a copy of the actual DEA number is available for submission.);

3.Current state substance registration certificate, if applicable (If allied health professional has applied for but not been issued a state substance registration certificate, a copy of the application requesting this certificate may be submitted until a copy of the actual certificate is available for submission.);

4.Statement of sponsoring health care provider (e.g., physician) or collaborative practice agreement, if applicable;

5.Proof of current professional liability insurance, including allied health professional name, inception and expiration date, and amount of coverage (If allied health professional has applied for but not been issued professional liability insurance, a copy of the application requesting coverage may be submitted until a copy of the approval of coverage is available for submission.);

6.Curriculum vitae or resume (All time periods from receipt of degree to present must be accounted for);

7.Current photograph;

8.Photo identification (ID). Additionally, photo ID should be presented in person at the hospital or health care organization where participation is desired; and

9.Separate pages or supplemental forms, if any, in page number order.

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I. PERSONAL IDENTIFICATION DATA

Name:	___________________________________________________________________________________________
	Last	Suffix First	Middle	Maiden Name	Degree

Residence:	__________________________________________________________ Phone:		_______________________________________
	__________________________________________________________ Fax:		_______________________________________
	__________________________________________________________
Primary Office Address:		__________________________________________________ Phone:	_______________________________________
		__________________________________________________ Fax:	_______________________________________
		__________________________________________________
Secondary Office Address:		__________________________________________________ Phone:	_______________________________________
		__________________________________________________ Fax:	_______________________________________
		__________________________________________________
Billing Office Address:		__________________________________________________ Phone:	_______________________________________
		__________________________________________________ Fax:	_______________________________________
		__________________________________________________
Credentialing Address:		__________________________________________________ Phone:	_______________________________________
		__________________________________________________ Fax:	_______________________________________
		__________________________________________________

Credentialing Contact:	_________________________________________________ Credentialing Email: ____________________________
Preferred Mailing Address:		Primary Office		Residence		Other (please specify)	_______________________________________________
Phys. Email Address: _________________________			Prac. Admin's Email: _____________________				Office Web Address: ______________________
Date of Birth: ________________________ Gender: _________					Place of Birth: ____________________________________________________
Social Security #: ______________________________________					Marital Status: _____________________________________________________
Citizenship: ___________________________________________					Spouse: _________________________________________________________
(If not a US citizen, please complete the next three fields)
Visa Status: ______________________________			Alien Reg. #: ________________________				Exp. Date: ________________________________

Language Spoken: ___________________________________________________________________________________________________________

ECFMG #:	-	-	-	Pager #: ______________________			Alpha		Digital		Voice
(if applicable):
Medicare #: ________________________________________________					Cellular #: ________________________________________________
Medicaid #: ________________________________________________					Answering service #: _______________________________________
UPIN #: ___________________________________________________					Are you taking new patients? _________________________________
EIN #: ____________________________________________________					Taxonomy Code: __________________________________________

NPI #: ____________________________________________________

Clinical Specialty/Subspecialty: _________________________________________________________________________________________________

Other interests in practice, research, etc.: _________________________________________________________________________________________

Name others with whom you are or will be associated in practice: ______________________________________________________________________

Nature of association:

Solo

Group

Partnership

Corporation

Effective Date: ____________________________

Other: (please specify) ________________________________________________________________________________________________________

Name of Practice (if applicable): _________________________________________________________________________________________________

Covering physician(s) to be called in my absence (Allied Health Professionals list sponsoring physician):

Name: ________________________________	Specialty: ____________________________	Telephone: _______________________________
Name: ________________________________	Specialty: ____________________________	Telephone: _______________________________
Name: ________________________________	Specialty: ____________________________	Telephone: _______________________________
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II. EDUCATIONAL DATA

(All periods of time must be accounted for from entrance into medical school to the present)

Please indicate if your name at any educational institution is different than the name listed on your application.

Yes

No

If YES, please identify other name(s): ___________________________________________________________________________________________

A. Schools

Undergraduate College/University: _______________________________________________________________________________________________

Address: ___________________________________________________________________________________________________________________

City/State/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): __________________________________________

Degree: ________________________________________________________________________________________ _____________ / ____________

From (mm/yy) To (mm/yy)

Medical/Dental/Other College: ___________________________________________________________________________________________________

Address: ___________________________________________________________________________________________________________________

City/State/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): __________________________________________

Degree: ________________________________________________________________________________________ _____________ / ____________

From (mm/yy) To (mm/yy)

B. Internships

Name: _______________________________________________________ _________________________________ _____________ / _____________

Type of InternshipFrom (mm/yy) To (mm/yy)

Address: ___________________________________________________________________________________________________________________

City/State/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): __________________________________________

During this internship, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? If YES, please explain on a separate sheet and attach.

Name: _______________________________________________________ _________________________________ _____________ / _____________

Type of InternshipFrom (mm/yy) To (mm/yy)

Address: ___________________________________________________________________________________________________________________

City/State/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): __________________________________________

During this internship, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? If YES, please explain on a separate sheet and attach.

Check if more than two internships were begun or completed. Please supply the same information on a separate sheet and attach.

C. Residencies

Name: _______________________________________________________ _________________________________ _____________ / _____________

Type of ResidencyFrom (mm/yy) To (mm/yy)

Address: ___________________________________________________________________________________________________________________

City/State/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): __________________________________________
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Chairman/Chief of Service: _____________________________________________________________________________________________________

During this residency, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? If YES, please explain on a separate sheet and attach.

Name: _______________________________________________________ _________________________________ _____________ / _____________

Type of ResidencyFrom (mm/yy) To (mm/yy)

Address: ___________________________________________________________________________________________________________________

City/State/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): __________________________________________

Chairman/Chief of Service: _____________________________________________________________________________________________________

During this residency, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? If YES, please explain on a separate sheet and attach.

Name: _______________________________________________________ _________________________________ _____________ / _____________

Type of ResidencyFrom (mm/yy) To (mm/yy)

Address: ___________________________________________________________________________________________________________________

City/State/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): __________________________________________

Chairman/Chief of Service: _____________________________________________________________________________________________________

During this residency, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? If YES, please explain on a separate sheet and attach.

Check if more than three residencies were begun or completed. Please supply the same information on a separate sheet and attach.

D. Fellowship and/or Other Postgraduate Training

Name: _______________________________________________________ _________________________________ _____________ / _____________

Type of FellowshipFrom (mm/yy) To (mm/yy)

Address: ___________________________________________________________________________________________________________________

City/State/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): __________________________________________

During this fellowship, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? If YES, please explain on a separate sheet and attach.

Name: _______________________________________________________ _________________________________ _____________ / _____________

Type of FellowshipFrom (mm/yy) To (mm/yy)

Address: ___________________________________________________________________________________________________________________

City/State/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): __________________________________________
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During this fellowship, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? If YES, please explain on a separate sheet and attach.

Name: _______________________________________________________ _________________________________ _____________ / _____________

Type of FellowshipFrom (mm/yy) To (mm/yy)

Address: ___________________________________________________________________________________________________________________

City/State/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): __________________________________________

During this fellowship, were you ever suspended, placed on probation, formally reprimanded, asked to resign or did you voluntarily resign? If YES, please explain on a separate sheet and attach.

Check if more than three fellowships were begun or completed. Please supply the same information on a separate sheet and attach.

E. Other Professional Training

School: _______________________________________________________ ______________________________ _____________ / _____________

Chairman/Chief of Service From (mm/yy) To (mm/yy)

Address: ___________________________________________________________________________________________________________________

City/State/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): __________________________________________

Degree: ____________________________________________________________________________________________________________________

School: _______________________________________________________ ______________________________ _____________ / _____________

Chairman/Chief of Service From (mm/yy) To (mm/yy)

Address: ___________________________________________________________________________________________________________________

City/State/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): __________________________________________

Degree: ____________________________________________________________________________________________________________________

Check if more than two training programs were begun or completed. Please supply the same information on a separate sheet and attach.

III. TEACHING APPOINTMENTS

Name: _________________________________________________ __________________________________ ________________________________

Department ChiefType of Appointment

Address: ___________________________________________________________________________________________________________________

City/State/ZIP: _______________________________________________________________________________ _____________ / _____________

City	St	ZIP	ZIP+	From (mm/yy)	To (mm/yy)
Phone: _________________________ Fax:	_________________________	Email (if available): __________________________________________

Name: _________________________________________________ __________________________________ ________________________________

Department ChiefType of Appointment

Address: ___________________________________________________________________________________________________________________

City/State/ZIP: _______________________________________________________________________________ _____________ / _____________

City	St	ZIP	ZIP+	From (mm/yy)	To (mm/yy)
Phone: _________________________ Fax:	_________________________	Email (if available): __________________________________________
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IV. POST-GRADUATE AND CONTINUING EDUCATION COURSES

Have you participated in post-graduate/continuing education courses in the last three years? If YES, please supply an attached list and/or certificate of attendance.

Do you have a cardio-pulmonary resuscitation certificate?

Please attach copies of all certificates.

V. LICENSURE INFORMATION

List all current and past professional health care licenses held and attach copies of all active licenses. Allied Health Professionals: list all certifications.

State:

License #:

Date Issued:

Expiration Date:

Status:

License Obtained by:

KY State:

_______

_____________

_____________

_____________

Active

Inactive

Exam

Reciprocity

State #2:

_______

_____________

_____________

_____________

Active

Inactive

Exam

Reciprocity

State #3:

_______

_____________

_____________

_____________

Active

Inactive

Exam

Reciprocity

State #4:

_______

_____________

_____________

_____________

Active

Inactive

Exam

Reciprocity

State #5:

_______

_____________

_____________

_____________

Active

Inactive

Exam

Reciprocity

State #6:

_______

_____________

_____________

_____________

Active

Inactive

Exam

Reciprocity

State #7:

_______

_____________

_____________

_____________

Active

Inactive

Exam

Reciprocity

State #8:

_______

_____________

_____________

_____________

Active

Inactive

Exam

Reciprocity

If licensed in more than eight (8) states, please supply the same information on a separate sheet and attach.

VI. DRUG ENFORCEMENT ADMINISTRATION INFORMATION (DEA)

(This application cannot be processed without current Federal DEA Certificate for each state in which you practice)

Federal DEA Certificate #:	_________________________________________	Expiration:	_______________________________________________
Federal DEA Certificate #:	_________________________________________	Expiration:	_______________________________________________

VII. STATE NARCOTICS REGISTRATION: CONTROLLED SUBSTANCE REGISTRATION (CSR)

Some states require additional CSR certificates. Attach copies of any additional CSR certificates you have.

State: _____________________________________________________________________________________________________________________

Certificate #: ____________________________________________________ Expiration: _______________________________________________

State: _____________________________________________________________________________________________________________________

Certificate #: ____________________________________________________ Expiration: _______________________________________________

VIII. PROFESSIONAL LIABILITY DATA

(This application cannot be processed without proof of amount of professional liability)

Name of Carrier: _____________________________________________________________________________________________________________

Address: ___________________________________________________________________________________________________________________

City: ________________________________________________	State: ______________________	ZIP: _____________________________
Policy #: ____________________________________________	Amount of Coverage: ________________________________________________

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Date of Inception: _____________________________________ Date of Expiration: __________________________________________________

Name of Agency: _____________________________________________________________________________________________________________

CLAIMS MADE

OCCURRENCE

(Check One)

Please list any other professional liability carriers you have used within the last five (5) years: _________________________________________________

____________________________________________________________________________________________________________________________

Answer the following questions:

If the answer is yes to any of the above questions, please explain the case(s) and the outcome(s) on the following Professional Liability Detail Sheet. Provide a full explanation including the name of the carrier, the date and specific information concerning any limitation, settlement or judgment.

PROFESSIONAL LIABILITY DETAIL SHEET

(Please copy this page if additional sheets are needed)

CHECK HERE IF NOT APPLICABLE

Please fill in the following details for each pending or settled malpractice suit or claim you have experienced:

Pending

Settled

Date: ____________________________

List the allegations: ___________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

Date of occurrence: ___________________________________________________________________________________________________________

Name of institution involved (i.e., hospital): _________________________________________________________________________________________

Name and address of insurance carriers involved: ___________________________________________________________________________________

Please supply the following details for each malpractice lawsuit in which you were a defendant, and which resulted in a jury award or court judgments against you.

Title of the court case: _________________________________________________________________________________________________________

The court case number: ________________________________________________________________________________________________________

The venue of the case (place where court case took place, such as County District Court or Circuit Court): ______________________________________

____________________________________________________________________________________________________________________________

Allegations listed in complaint: __________________________________________________________________________________________________

Date of incident leading to complaint: _____________________________________________________________________________________________

Place of incident: _____________________________________________________________________________________________________________

Name and address of malpractice insurance carrier: _________________________________________________________________________________

____________________________________________________________________________________________________________________________

Amount of jury award or amount awarded by the court: _______________________________________________________________________________

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IX. CERTIFICATION BY AMERICAN BOARD OF MEDICAL SPECIALTIES OR AMERICAN OSTEOPATHIC ASSOCIATION

2.	If yes, list full name of certifying board and date which you obtained certification/recertification:
	_____________________________________________________________________________	Date: ____________________________
	_____________________________________________________________________________	Date: ____________________________
	_____________________________________________________________________________	Date: ____________________________
	_____________________________________________________________________________	Date: ____________________________
	_____________________________________________________________________________	Date: ____________________________

3.If you are not yet certified but have applied to a specialty board for examination, give the name of the board and date of application:

_____________________________________________________________________________

Date: ____________________________

4.If status is one of eligibility, provide year when eligibility will terminate under rules of the specific board: _____________________________________

5.List date of next required recertification (if applicable): ____________________________________________________________________________

X. INDIVIDUAL PRACTICE INFORMATION

Please answer each of the following questions in full. If the answer to any question is "yes," please provide full explanation of the details on a separate sheet and attach.

XI. PERSONAL HEALTH STATUS

Please answer each of the following questions in full. If the answer to any question is "yes," please provide full explanation of the details on the appropriate Explanation Sheet.

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XII. PROFESSIONAL SOCIETIES

Membership in local, state, or national medical societies

Dates

Name: _________________________________________________________________________________ _____________ / _____________

From (mm/yy) To (mm/yy)

Address: ____________________________________________________________________________________________________________

City: ________________________________________________ State: ______________________ ZIP: ______________________

Name: _________________________________________________________________________________ _____________ / _____________

From (mm/yy) To (mm/yy)

Address: ____________________________________________________________________________________________________________

City: ________________________________________________ State: ______________________ ZIP: ______________________

Name: _________________________________________________________________________________ _____________ / _____________

From (mm/yy) To (mm/yy)

Address: ____________________________________________________________________________________________________________

City: ________________________________________________ State: ______________________ ZIP: ______________________

Name: _________________________________________________________________________________ _____________ / _____________

From (mm/yy) To (mm/yy)

Address: ____________________________________________________________________________________________________________

City: ________________________________________________

State: ______________________

ZIP: ______________________

1.I would like to use this application for membership in the _________Lexington___________ Medical Society and the KMA. A separate dues statement will be sent.

2.I am already a member of my local medical society. Please specify society: _____________________________________________________

XIII. PROFESSIONAL EMPLOYMENT AND AFFILIATIONS

A. Employment

List in chronological order all professional employment since completion of post-graduate education, starting with your current position. This includes all hospitals, corporations, military assignments, government agencies, group practices, other healthcare facilities or other types of activity. Complete addresses must be included. Date must be in MM/YY format. If you have a gap in employment of more than thirty (30) days, please explain on a separate page. "See CV" is not acceptable. Please attach additional sheets if more space is needed.

Name: ________________________________________________ Department: __________________________ _____________ / _____________

From (mm/yy) To (mm/yy)

Address: __________________________________________________________ Type of Privileges/Position: _______________________________

City/St/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): ________________________________________

Reason for leaving: ________________________________________________________________________________________________________

Name: ________________________________________________ Department: __________________________ _____________ / _____________

From (mm/yy) To (mm/yy)

Address: __________________________________________________________ Type of Privileges/Position: _______________________________

City/St/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): ________________________________________

Reason for leaving: ________________________________________________________________________________________________________

Name: ________________________________________________ Department: __________________________ _____________ / _____________

From (mm/yy) To (mm/yy)

Address: __________________________________________________________ Type of Privileges/Position: _______________________________

City/St/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): ________________________________________

Reason for leaving: ________________________________________________________________________________________________________

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Name: ________________________________________________ Department: __________________________ _____________ / _____________

From (mm/yy) To (mm/yy)

Address: __________________________________________________________ Type of Privileges/Position: _______________________________

City/St/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): ________________________________________

Reason for leaving: _________________________________________________________________________________________________________

B. Affiliations

List in chronological order all professional affiliations since completion of post-graduate education, starting with your current position. This includes all hospitals, corporations, military assignments, government agencies, group practices, other healthcare facilities or other types of activity. Complete addresses must be included. Date must be in MM/YY format. If you have a gap in employment of more than thirty (30) days, please explain on a separate page. "See CV" is not acceptable. Please attach additional sheets if more space is needed.

Name: ________________________________________________ Department: __________________________ _____________ / _____________

From (mm/yy) To (mm/yy)

Address: __________________________________________________________ Type of Privileges/Position: _______________________________

City/St/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): ________________________________________

Reason for leaving: ________________________________________________________________________________________________________

Name: ________________________________________________ Department: __________________________ _____________ / _____________

From (mm/yy) To (mm/yy)

Address: __________________________________________________________ Type of Privileges/Position: _______________________________

City/St/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): ________________________________________

Reason for leaving: ________________________________________________________________________________________________________

Name: ________________________________________________ Department: __________________________ _____________ / _____________

From (mm/yy) To (mm/yy)

Address: __________________________________________________________ Type of Privileges/Position: _______________________________

City/St/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): ________________________________________

Reason for leaving: ________________________________________________________________________________________________________

Name: ________________________________________________ Department: __________________________ _____________ / _____________

From (mm/yy) To (mm/yy)

Address: __________________________________________________________ Type of Privileges/Position: _______________________________

City/St/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): ________________________________________

Reason for leaving: ________________________________________________________________________________________________________

Name: ________________________________________________ Department: __________________________ _____________ / _____________

From (mm/yy) To (mm/yy)

Address: __________________________________________________________ Type of Privileges/Position: _______________________________

City/St/ZIP: _______________________________________________________________________________________________________________

City	St	ZIP	ZIP+	Country
Phone: _________________________ Fax:	_________________________	Email (if available): ________________________________________

Reason for leaving: ________________________________________________________________________________________________________

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XIV. PEER REFERENCES

Name three physicians who have personal knowledge of your current clinical abilities, and ethical character, who will provide specific written comments on these matters upon request from Hospitals, Medical Societies, or Authorized Credentialing Services. The named individuals must have acquired the requisite knowledge through recent observation of your professional practice over a reasonable period of time, and at least one must have had organizational responsibility for your performance. The individuals should not be related to you by blood or marriage, training directors, partners/associates in your current group practice, or anyone with whom you have or anticipate having a financial relationship. Requested sources: practitioner in same specialty or practitioners with whom you have a referral pattern. If you recently completed training, you may use chief resident or other training colleague. Allied Health Professional should list their sponsoring physician, another physician and one peer from the same specialty as the applicant. Please note that you may be required to follow further directions of an individual hospital or facility in order to accommodate variations in medical staff bylaws.

Reference: ________________________________________________________________________________________________________________

Address: __________________________________________________________________________________________________________________

City/St/ZIP: _____________________________________________________________________________ Country: ________________________

Phone: _________________________ Fax: _________________________ Email (if available): _________________________________________

Reference: ________________________________________________________________________________________________________________

Address: __________________________________________________________________________________________________________________

City/St/ZIP: _____________________________________________________________________________ Country: ________________________

Phone: _________________________ Fax: _________________________ Email (if available): _________________________________________

Reference: ________________________________________________________________________________________________________________

Address: __________________________________________________________________________________________________________________

City/St/ZIP: _____________________________________________________________________________ Country: ________________________

Phone: _________________________ Fax: _________________________ Email (if available): _________________________________________

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XV. AUTHORIZATION AND RELEASE OF APPLICANT (HEALTHCARE FACILITY RELEASE)

(Please read carefully before signing)

As a condition of applying for/accepting medical staff appointment or clinical privileges at the healthcare facilities listed in this application ("Hospital"), and whether or not my application is accepted, I acknowledge, consent, and agree as follows:

A)I extend absolute immunity to, and release from all liability, the Hospital, its authorized representatives, and third parties (as defined in subsection C below), for any good faith communications, recommendations, disclosures or administrative action involving and pertaining to: (1) applications for appointment, reappointment or clinical privileges; (2) periodic reappraisals; (3) proceedings for suspension or reduction of clinical privileges or for denial or revocation of appointment, reappointment, or any other disciplinary action; (4) summary suspensions; (5) hearings and appellate reviews; (6) care evaluations; (7) utilization reviews; (8) any other healthcare facility, medical staff, department, service or committee activities; (9) my professional qualifications, credentials, clinical competence, character, mental or emotional stability, physical condition, ethics or behavior; and (10) any other matter that might directly or indirectly impact or reflect on my competence, on patient care or on the orderly operation of the Hospital.

B)I will make myself available for interviews and acknowledge the burden of producing updated current information as to all questions on this application and such other information reasonably necessary to evaluate my qualifications. The Hospital and its authorized representatives may consult with and obtain information, including otherwise privileged or confidential information, from the Hospital's medical staff appointees and employees and from any third party bearing on my professional qualifications, all matters listed in subsection A, and any other matters bearing on my satisfaction of the criteria for reappointment to the medical staff. I authorize all persons and organizations having any knowledge of such matters to release said information to the Hospital or its authorized representatives upon request and I consent to the reporting of disciplinary information described below in section C.

C)The term "Hospital and its authorized representatives" means the Hospital, its governing entity, persons who have any responsibility for or knowledge pertaining to the matters outlined in subsection A above, and authorized Centralized Verification Organization (CVO). The term "third party" means any individual, including a reappointee to the medical staff or other healthcare facilities, other physicians and health practitioners, government agencies, professional liability insurers, and other entities from whom or by whom the Hospital, authorized CVO, or other authorized representatives have requested or supplied information pertaining to matters in subsection A above.

I acknowledge and agree that: (1) medical staff reappointment and clinical privileges are not a right; (2) applications and requests will be evaluated in accordance with prescribed procedures defined in the Hospital and medical staff bylaws, rules and regulations; (3) I shall be bound by the medical staff bylaws, rules and regulations, and corporate compliance programs, as amended from time to time, of hospitals to which I now and may subsequently apply;

(4)I pledge to provide for continuous care for my patients in the hospital; (5) Hospital or its authorized representatives and third parties acting in their official capacities will notify authorized CVO and appropriate governmental agencies, boards or professional associations of disciplinary or professional action taken with respect to me if required to be reported to the Kentucky Medical Licensure Board by KRS 311.606 or if required to be reported by the authorized CVO, by medical staff bylaws, or by any other state or federal law; and (6) that this authorization, attestation and release is irrevocable for any period during which I am an applicant for or have medical staff privileges at Hospital, or, if later in time, for as long as Hospital may be under a duty to report information pursuant to the Health Care Quality Improvement Act of 1986. Pub. L. 99-660.

I represent and warrant that at the time of this application and at all times while I maintain medical staff membership that (1) I am not nor have I ever been, excluded or suspended for any period of time whatsoever from participation in any state or federal health care program, including Medicare and Medicaid;

(2)I have not been convicted under any state or federal law of any offense for which I could face mandatory exclusion from participation in any state or federal health care program, including Medicare and Medicaid; (3) I have not committed any act for which I may be permissibly excluded from participation in any state or federal health care program, including Medicare and Medicaid; (4) I do not hold, and have never held, a direct or indirect ownership or controlling interest of five percent (5%) or more in any entity that has been excluded or suspended for any period of time whatsoever from participation in any state or federal health care program, including Medicare and Medicaid, nor have I ever been an officer, director, agent, or managing employee of any such entity; and (5) I have never been convicted of a federal health care offense as defined in 18 U.S.C. § 24, including any theft, embezzlement, fraud, or other acts as prohibited therein with regard to any public or private health plan. I agree to notify Hospital immediately in the event I am unable to maintain one or more of these representations.

D)Information and documents derived from or compiled in connection with matters listed in subsection A above, shall be privileged and confidential to the fullest extent permitted by law.

Information contained in or attached to this application is accurate and complete to the best of my knowledge. Any misrepresentation, misstatement, or omission, whether intentional or not, may constitute cause for immediate rejection of this application and termination of any status or privilege granted in reliance upon it.

Applicant's Signature: _______________________________________________________

Date: ________________________________

KAPER-1 (04/2009) [CCForm3]

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ACKNOWLEDGEMENT STATEMENT

The following statement is required (by Medicare/Champus regulation) to be signed by each physician when he/she joins the Medical Staff. This must be signed and dated in the physician’s own handwriting using his/her legal signature (initials are not accepted).

According to federal guidelines, stamped signatures and typed dates are not acceptable.

MEDICARE/CHAMPUS

“Notice to physicians: Medicare/Champus payment to hospitals is based in part on each patient’s principle and secondary diagnoses and the major procedures performed on the patient, as attested to by the patient’s attending physician by virtue of his/her signature in the medical record. Anyone who misrepresents, falsifies, or conceals essential information required for payment of federal funds may be subject to fine, imprisonment or civil penalty under applicable federal law.”

I certify that I have received the above statement.

Signature: _________________________________________ Date: ___________

Type or Printed Name: ___________________________________________________

KAPER-1 (04/2009) [CCForm3]

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