(1) current - guam regional medical city · are pre-requisites for medical staff appointment. (1)...

133 Route 3, Dededo, Guam 96929 - Tel: 671-645-5500

Dear Doctor:

Thank you for your interest in applying for staff membership and privileges with Guam Regional Medical City. The following are pre-requisites for Medical Staff appointment.

(1) Current unrestricted license to practice medicine in the Territory of Guam and a current unrestricted DEA.

(2) Be board certified, or be eligible to enter the certification examination system in accordance with the training and/or

experience requirements defined by the applicable certifying board. The certifying board must be one of the following:

Must hold an M.D. or D.O. degree issued by a medical or osteopathic school recognized by the Medical Board of Guam and accredited by the Liaison Committee on Medical Education or the American Osteopathic Association (AOA) at the time of granting the degree and a valid, unrevoked and unsuspected certificate to practice medicine issued by the Guam Medical Board of Guam.

Board Certified by an American of Medical Specialists (ABMS) or AOA Board in the specialty or specialties in which the applicant seeks Clinical Privileges, or obtain board certification within two (2) years.

Board Certified by the American Board of Oral & Maxillofacial Surgery (ABOMS) or obtain board certification within two (2) years I accordance with the ABOMS criteria.

Board Certified by specialty board recognized by the Council of Podiatric Medical Education (CPME) of the American Podiatric Medical Association, or obtain board certification within two (2) years in accordance with the relevant CPME board’s criteria.

(3) Professional liability insurance in the minimum amount of $1,000,000/$3,000,000 with an acceptable carrier in at least the minimum amounts specified by the Executive Committee and the Governing Board.

Attached you will find the following:

Pg. 1 Checklist for Department and Specialty Pg. 3 Initial Credentialing Application Form for

Medical Staff Appointment Pg. 9-10 Health Status & Annual TB Questionnaire Form Pg. 12 Medicare/Tricare Attestation Form Pg. 13 CME Log Form Pg. 14 Conditions of Appointment and Release of

Liability Form

Pg. 15 Confidential Malpractice Claims Form (to be completed if there are ANY claims/Board Actions)

Pg. 16 Conflict of Interest Statement Pg. 18 Network Usage Form – Exhibit A (Independent

Physicians) Pg. 19 Consent to Publicity Release Pg. 20 Application Fee Invoice

In order to complete your application, please provide the following (INDICATE IF N/A):

Current color photo (2x2 passport size) Current copy of a Government issued Passport,

Identification card or Driver’s License Current Guam Medical License State Medical License (if any) Professional Liability Insurance Policy Certificate

of Coverage ECFMG Certificate (International Graduate) Medical School Diploma

Internship, Residency, and Fellowship Certificates Current Federal Narcotics Registration Certification

(DEA) State Controlled Substance Registration (CSR) Evidence of Board Certification and Re-certification Current BLS, ACLS, ATLS, PALS certification. BLS is

required for all practitioners Curriculum Vitae Documentation of PPD or Chest X-ray

133 Route 3, Dededo, Guam 96929 - Tel: 671-645-5500

Upon completion, the application form may be submitted to our office, located at 133 Route 3, Dededo, Guam 96929, 3rd Floor, Medical Staff Office. Processing of your application cannot begin until all information has been received. A return envelope is provided for your convenience. Your application will be deemed incomplete if the application or any of the requested documents are not returned within 30 days and will be considered automatic withdrawal. You will be contacted if any additional information is required to complete your file. Following verification of the application information, your application will be forwarded to the appropriate Department Chair and/or the Section Chair which for review and recommendation. If the Department Chair and/or the Section Chair recommend approval, your application will be forwarded to the Credentials Committee for review and recommendation prior to final action by the Executive Committee and the Governing Body. Please complete your application, answer all questions carefully to the best of your knowledge. An initial application membership of $400.00 which is non-refundable MUST accompany this application. The check must be payable to “Guam Regional Medical City”. Any questions which are answered and found to be incomplete or inaccurate upon committee review may delay your application and/or require an interview. If the application is not returned within 30 days of the above date, it will be considered automatic withdrawal of application. If you have any questions or I can of further assistance, please feel free to contact our Credentialing Specialists, Tanya Grant - Phone: (671) 645-5546, Email [email protected] or Erlinda Rabon - Phone: (671) 645-5544, Mobile (671) 685-3279, Email [email protected]

Sincerely, Medical Staff Department

Attachments

mailto:[email protected]

mailto:[email protected]

NAME: _____________________________ DATE: ______________________________

Page 1 of 20

CHECKLIST FOR DEPARTMENT AND SPECIALTY

INITIAL APPLICATION FOR MEDICAL STAFF APPOINTMENT (PLEASE INDICATE SPECIALTY AREA IN WHICH YOU ARE REQUESTING PRIVILEGES)

(MD, DO, DPM, NP, CRNA, CNW, PA)

ANESTHESIA MD Mid-Level PEDIATRICS MD Mid- Level

Anesthesia Neonatal-Perinatal Medicine

Cardiothoracic Anesthesia Pediatrics

Pain Management Pediatric Cardiology

Pediatric Endocrinology

CARDIOVASCULAR MD Mid-Level Pediatric/Hematology/Oncology

Cardiology Pediatric Neurology

CV/Thoracic Surgery

Vascular Surgery BEHAVIORAL HEALTH MD Mid-Level

Interventional Cardiology Psychiatry

Psychology

EMERGENCY MEDICINE MD Mid-Level Additive Medicine

Emergency Medicine

Urgent Care RADIOLOGY MD Mid-Level

Radiology

MEDICINE/FAMILY PRACTICE MD Mid- Level Interventional Radiology

Allergy and Immunology Radiology Oncology

Critical Care Diagnostic Radiology

Dermatology Nuclear Medicine

Endocrinology

Family Medicine SURGERY MD Mid-Level

Gastroenterology Colon & Rectal Surgery

Infectious Disease Dentistry

Internal Medicine Dermatology Surgery

Nephrology General Surgery

Neurology Hand Surgery

Oncology/Hematology Neurological Surgery

Pathology Ophthalmology

Physical Medicine and Rehab Oral / Maxillofacial Surgery

Psychiatry Orthopedic Surgery

Pulmonary Disease Otolaryngology

Rheumatology Pediatric Dentistry

Pediatric Surgery

OBSTETRICS AND GYNECOLOGY MD Mid-Level Pediatric/Reconstructive Surgery

Gynecology Podiatry

Gynecology / Oncology Urology Infertility-Reproductive-

Endocrine - Maternal Wound Healing / Hyperbaric

Medicine

Fetal Medicine

OB/GYN

NAME: _____________________________ DATE: ______________________________

Page 2 of 20

Medical Staff Category

Category

Definition

□ Provisional Staff

All new appointees to the Medical Staff must first serve a Provisional Staff appointment of not less than six (6) months, and not more than two (2) years. Provisional Staff members may serve as voting members of a Committee but may not hold Committee or elective office or vote. They are required to pay dues and attend Medical Staff meetings.

□ Active Staff

The Active Staff engages in at least 20 patient encounters every two (2) years. Eligible to vote, hold office, and is required to pay dues and attend Medical Staff meetings.

□ Courtesy Staff

The Courtesy Staff engages in less than 20 patient encounters every two (2) years. Must pay dues, are not eligible to vote or hold office, and are not required to serve on Committees or attend Medical Staff meetings.

□ Consulting Staff

The Consulting Staff consist of Practitioners who will lend prestige to the Hospital and/or who can improve the care of the patients by virtue of their professional expertise. They may not hold office or vote, however may serve on Committees with or without vote. They are obligated to pay dues.

□ Emeritus Staff

The Emeritus Staff consist of Practitioners who are not active in the Hospital and who have served on the Medical Staff for ten (10) or more years. They are not eligible to vote, hold office, admit patients or have clinical privileges and have no assigned duties. However, they may serve on Committees with or without vote at the discretion of the Executive Committee. They are not required to pay dues or have valid license to practice medicine in Guam.

□ Affiliated Staff The Affiliated Staff consist of Residents and/or Fellows at the Hospital or at other training programs who have not completed full training in their specialty and/or who do not meet Board Certification or eligibility for Board Examination requirements. They are not required to pay dues, vote or hold Medical Staff Office. However, they may attend Medical Staff meetings and serve on Committee with vote at the discretion of Executive Committee.

NAME: _____________________________ DATE: ______________________________

Page 3 of 20

CREDENTIALING APPLICATION

Professional Information

Last Name: First Name: M.I.: Generational Suffix:

Other Name Used: Degree: Gender (optional):

SSN:

Date of Birth: Place of Birth: Citizenship:

Visa Status: Languages Spoken in addition to English:

Current Life Support BLS ACLS PALS NRP ATLS Other Certifications:

Do you know YES sign language?: NO

Please Circle One of the Following:

PCP Specialist Both Allied Health Professional

Primary PRACTICING Specialty:

Secondary PRACTICING Specialty:

10-digit NPI Number: Medicare UPIN / Number:

Mailing Address: Street:

City: State: Zip:

Phone: E-mail Address:

Professional References (Must be a medical professional, preferably within same specialty.)

Reference 1 Full Name:

Title: Specialty:

Current Street Address: State: Zip:

Phone: Email address:


Title: Specialty:

Current Street Address: State:

Zip:

Phone: Email address:


Title: Specialty:

Current Street Address: State: Zip:

Phone: Email address

ATTACH 2X2 PHOTO

NAME: _____________________________ DATE: ______________________________

Page 4 of 20

Education Information Undergraduate Education School:

City: State:

Country: Start Date: Grad. Date: Degree:

Major Course of Study:

Professional / Medical Education

Professional / Medical Education School:

City: State:

Country: Start Date: Grad. Date: Degree:

Post-Graduate Training Please Check One of the Following: Internship Residency Fellowship Other

Institution: City: State:

Country: Start Date: End Date:

Specialty: Completed?: YES / NO













Education Council for Foreign Medical Graduates ECFMG Number:

Issue Date:

NAME: _____________________________ DATE: ______________________________

Page 5 of 20

Hospital Privilege Information (Please list current and past) Primary Admitting Facility

Hospital Name: Privileges Held:

Address: City: State: Zip:

Number of Admissions per:

Phone: From: To: Month: Year:

Other Admitting Facility Hospital Name: Privileges Held:



Phone:

From: To: Month: Year:

















NAME: _____________________________ DATE: ______________________________

Page 6 of 20

Work History and Professional Liability Insurance Information

Practice History Please fill in all information for each position. Please list positions from present to graduation from medical school. Attach additional sheets as necessary.

From: _______ To:_______

m/y m/y

Practice Name: City, State, Zip:

Address: Phone:

From: _______ To:_______

m/y m/y


Address: Phone:

From: _______ To:_______

m/y m/y


Address: Phone:

From: _______ To:_______

m/y m/y


Address: Phone:

From: _______ To:_______

m/y m/y


Address: Phone:

Please explain any gaps of 30 days or more:

Current Professional Liability Insurance

Carrier Name:

Carrier Address: City: State: Zip:

Policy Number: Dates of Coverage From:

To:

Policy Limits Per Claim: $ ________

Agg: $ ___________

Previous Professional Liability Insurance

Carrier Name:


Policy Number: Dates of Coverage From:

To:

Policy Limits Per Claim: $_________

Agg: $ ___________

Previous Professional Liability Insurance

Carrier Name:


Policy Number:

Dates of Coverage From:

To:

Policy Limits Per Claim: $ ________

Agg: $ ___________

NAME: _____________________________ DATE: ______________________________

Page 7 of 20

License and Certification Information

State License Information Please list all current and previous licenses held. If you answer No to “In Good Standing,” please attach an explanation.

State: License Number: Issue

Date: Exp. Date: In Good

Standing?: YES / NO

State: License Number: Issue Date:

Exp. Date: In Good Standing?: YES / NO





Drug Enforcement Administration (DEA) Certificate. If you answer No to “In Good Standing,” please attach an explanation.

Cert. Number: Exp. Date: In Good Standing?: YES / NO



State Controlled Dangerous Substance (CDS) Certificate Information. If you answer No to “In Good Standing,” please attach an explanation.

State: Cert. Number: Issue Date:








Board Certification Information Certification Status: Certified Eligible If Eligible, Exam Date:

Certifying Board: Specialty:

Cert. Number: Original Cert. Date:

ReCert. Date: Exp. Date:

Certification Status: Certified Eligible If Eligible, Exam Date:




Certification Status: Certified Eligible If Eligible, Exam Date:




NAME: _____________________________ DATE: ______________________________

Page 8 of 20

Health Status

1. Do you have a chronic or recurring illness, mental or physical disability that may affect your ability to perform privileges? YES/NO

If yes, please explain:

2. Are you currently or have you in the past been dependent on or treated for alcohol or drugs? YES / NO


3. Are you currently taking medication or undergoing treatment or therapy that is likely to affect your ability to perform privileges requested?

YES/NO


TB Skin Test The Guam Department of Public Health Services and Guam Regional Medical City requires each medical staff member provide evidence of freedom from infectious pulmonary tuberculosis annually. This evidence of freedom from infectious pulmonary tuberculosis can be established by:

a. A report of negative Mantoux skin test; b. A report of a negative chest x-ray; or c. If the medical staff/allied health staff member has had a positive Mantoux skin test, another physician’s

written statement that he or she is free from infectious pulmonary tuberculosis and completion of the enclosed Annual Tuberculosis Questionnaire (found on the accompanying page).

If a medical staff or allied health member signs this attestation and cannot provide evidence, DHS has indicated that it will report the physician to AMB/BOMEX or the appropriate licensing board.

I attest that I was evaluated for infectious pulmonary tuberculosis in / / _____ I have attached the following evidence to demonstrate that I am free from infectious pulmonary tuberculosis:

A report of a negative Mantoux skin test;

A report of a negative chest X-ray; or

Although I had a positive Mantoux skin test, I have another physician’s statement that I free from infectious pulmonary tuberculosis and have enclosed a completed Annual Tuberculosis Questionnaire.

**MUST INCLUDE COPY OF TB TEST, CHEST X-RAY OR PHYSICIAN’S STATEMENT WITH RETURN OF APPLICATION,

INCLUDING ANNUAL TB QUESTIONNAIRE IF APPLICABLE

NAME: _____________________________ DATE: ______________________________

Page 9 of 20

ANNUAL TUBERCULOSIS QUESTIONNAIRE

FOR THE INDIVIDUAL WITH A POSITIVE TB SKIN

All Guam Regional Medical City practitioners with positive tuberculin skin tests must complete and sign the following questionnaire annually. Please check "yes" or "no" next to each symptom. If you check "yes", then describe the symptom including date of onset at the bottom of this page.

SYMPTOM Unexplained weight loss

YES NO

Easily fatigued

Loss of appetite

Hemoptysis (coughing up blood)

Productive, prolonged cough (over 3 weeks duration)

Fever, chills

Night sweats

The current recommendation from the Centers for Disease Prevention and Control (CDC) regarding annual chest x-rays for the individuals with a positive TB skin test is as follows:

“Health care workers (HCWs) with positive PPD tests should have a chest radiograph as part of the initial evaluation of their PPD test; if negative, repeat chest radiographs are not needed unless symptoms develop that may be due to TB.”

Therefore, if you are experiencing any of the above symptoms you should your physician, as you may be manifesting symptoms of tuberculosis.

Comments: ______________________ __________________________________________________________________________________________________________

I understand by typing in my name, this will be considered an electronic signature.

_____________________________________________ _______________________________________________ Print Name Signature

_____________________________________________ _______________________________________________ Department Date

NAME: _____________________________ DATE: ______________________________

Page 10 of 20

Professional Questions YES NO

1 Has your license to practice in any jurisdiction ever been denied, restricted, limited, suspended, or revoked, either voluntarily or involuntarily?

2 Have you ever been reprimanded by any state-licensing agency, or are you currently under investigation by any state-licensing agency with respect to your license to practice?

3 Has your DEA or state controlled substances registration ever been restricted, limited, suspended, or revoked, either voluntarily or involuntarily?

4 Are you currently under any investigation with respect to your DEA or state controlled substances registration?

5 Have you ever been denied hospital privileges or have you ever had any hospital privileges revoked, suspended, reduced, or non-renewed?

6 Have you ever voluntarily relinquished or voluntarily limited any hospital privileges?

7 Have any disciplinary proceedings ever been instituted against you or are any disciplinary actions now pending with respect to your hospital privileges?

8 Have you ever been reprimanded, censured, excluded, suspended, denied, or disqualified from participating in Medicare, Medicaid, or any other governmental or quasi-governmental health-related program?

9 Have any complaints ever been filed against you with a medical society or licensing authority?

10 Are there any professional liability claims currently pending against you?

11 Have any professional liability claim settlements, of any kind, been paid by you or paid on your behalf in the last five years?

12 Have any professional liability judgments ever been entered against you in the last five years?

13 Have you ever been denied professional liability insurance coverage or had your professional liability insurance coverage cancelled by your carrier?

14 Have you ever been convicted of a felony or other crime (other than a minor traffic offense) or do you have any felony or other criminal charges pending (other than for minor traffic offenses)?

15 Have you ever been refused participation in a network of managed care organizations (HMO or PPO), or been disciplined by or terminated from such a plan or organization?

16 Has any information pertaining to you ever been reported to the National Practitioner Data Bank (NPDB)?

17 Do you have a medical condition, which in any way impairs or limits your ability to practice medicine with reasonable skill and safety? If the answer is Yes, please answer questions 18 and 19.

18 Are the limitations or impairments caused by your medical condition reduced or ameliorated because you receive on-going treatment (with or without medications) or participate in a monitoring program?

19 Are the limitations or impairments caused by your medical condition reduced or ameliorated because of the field of practice, the setting, or manner in which you have chosen to practice?

20 Do you use any chemical substance(s) that might in any way impair or limit your ability to practice medicine with reasonable skill and safety?

21 Are you currently participating in a supervised rehabilitation program or professional assistance program, which monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous substance?

**Please attach appropriate explanatory information to any “YES” answers above.

(It is the responsibility of each Medical Staff member to disclose any Lawsuit, Malpractice, Settlements that occur.)

Should appointment be granted, I hereby agree to abide by the Medical Staff Bylaws and Rules and Regulations of this Facility and further agree to abide of such Facility policies and procedures that are currently in force and from time to time enacted.

__________________________________________________ __________________________________

Applicant’s Signature Date

NAME: _____________________________ DATE: ______________________________

Page 11 of 20

APPLICANT'S APPLICATION STATEMENT I understand that it is my responsibility to produce adequate information so that my application can be properly evaluated. In addition to the information provided in this application, I also agree to provide the Hospital with any additional information that the Hospital or one of its authorized representatives may request. MY FAILURE TO PROVIDE ANY REQUESTED INFORMATION WILL CAUSE MY APPLICATION TO BE INCOMPLETE AND WILL PREVENT IT FROM BEING PROCESSED. I have read, reviewed and answered all questions on the Guam Regional Medical City application and attest to their accuracy. ________________________________________ _________________________ Applicant’s Signature Date ____________________________________________ Print Name

NAME: _____________________________ DATE: ______________________________

Page 12 of 20

MEDICARE/TRICARE ATTESTATION STATEMENT

NOTICE TO PRACTITIONERS

“Medicare, and/or other federally funded program payments to healthcare entities are based on patient’s principal and secondary diagnosis and the major procedures

performed on the patient, as attested to by the patient’s 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 fine, imprisonment, or civil penalty under applicable federal laws”

***************************************************************************************************************

I acknowledge that I have read the above statement. _________________________________________ _____________________________ Signature Date _________________________________________ Print Name

NAME: _____________________________ DATE: ______________________________

Page 13 of 20

CONTINUING MEDICAL EDUCATION

Every calendar year, each person holding an active medical license to practice medicine in the Territory of Guam shall complete a minimum of 100 credit hours of continued medical education. Please list below or attach a complete list of Continuing Medical Education Programs attended during the past two (2) years.

DATES COURSES NUMBER OF HOURS

___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ TOTAL NUMBER OF HOURS: _____________________________________

NAME: _____________________________ DATE: ______________________________

Page 14 of 20

CONDITIONS OF APPOINTMENT/REAPPOINTMENT AND

RELEASE OF LIABILITY

By applying for appointment/reappointment to the Medical Staff of Guam Regional Medical City, I hereby:

► signify my willingness to appear for interviews in regard to my application;

► authorize the Hospital, Medical Staff and their representatives to consult with my prior and current associates and others who may have information bearing on my professional competence, character, health status, ethical qualifications and ability to work cooperatively with others;

► consent to the inspection by the Hospital, Medical Staff and their representatives of all documents that may be material to an evaluation of

my qualifications and competence to carry out the privileges requested, and consent to the full unconditional release of such information from other hospitals or organizations;

► consent to the sharing between Guam Regional Medical City and their Medical Staff department and committees of all information, including

confidential information, bearing on my professional competence, character, health status, ethical qualifications and ability to work cooperatively with others;

► release from liability all representatives of the Hospital and Medical Staff for their acts performed in connection with the evaluation of my

application, credentials and qualifications;

► release from liability any and all individuals and organizations who provide information to the Hospital or the Medical Staff concerning my professional competence, professional ethics, character, physical and mental health status, release of malpractice claims history and coverage, as well as other qualifications/criteria for Staff appointment and clinical privileges;

► authorize and consent to Hospital representatives providing to other hospitals, medical associations, licensing boards, and other

organizations concerned with provider performance and the quality and efficiency of patient care any information relevant to such matters that the Hospital may have and release Hospital representatives from liability for so doing;

► acknowledge that I have received, or have access to, the By-Laws of the Medical Staff and any other manuals and policies relevant to the

appointment and reappointment process and to clinical practice in general at the Hospital, and agree to be bound by the terms thereof in all matters relating to medical staff membership and clinical privileges and to the consideration of my application for appointment/reappointment to the Medical Staff and for clinical privileges;

► acknowledge that the provisions of said Medical Staff By-Laws relating to confidentiality and release from liability are express conditions

to my application for, and acceptance of, appointment to the Medical Staff and the continuation of such appointment and to my exercise of clinical privileges;

► pledge to maintain an ethical practice, to provide for continuous care for my patients, and to refrain from delegating the responsibility for

care of my patients to any practitioner not qualified to undertake that responsibility;

► acknowledge that I, as an applicant for appointment and privileges, have the burden of producing adequate information for a proper evaluation of my professional, ethical and other qualifications for membership and clinical privileges and for resolving any doubts about such qualifications, and that failure to sustain the burden of producing adequate information shall be deemed a voluntary withdrawal of my application;

ALL INFORMATION SUBMITTED BY ME IN THIS APPLICATION IS TRUE TO MY BEST KNOWLEDGE AND BELIEVE Signature: _______________________________________________ Date: _____________________

NAME: _____________________________ DATE: ______________________________

Page 15 of 20

Confidential Information Sheet For Information Pertaining to Malpractice Litigation

and Professional Complaints

For each lawsuit or complaint, please furnish the following information and attach a copy of the complaint including your response to the complaint and level of participation. It is your responsibility to provide external verification (i.e., statement from an attorney, court records, etc.) of your response. You may choose to have your attorney complete this form. Name(s) of plaintiff(s) or complainant(s): Month/Year of Incident? Where incident occurred? _ Describe the nature of Incident? (Complaint, Allegation): _ Provide a narrative description of your participation/level of care:

Outcome of Incident? Pending Dismissed Dropped Settled, Amount? _____________________

Verdict for you, Amount? _________ Verdict for plaintiff, Amount? _____________________ Represented by Legal Counsel for this claim/malpractice lawsuit?

No Yes If yes, give the name and address of counsel.

Name:

Address:

Telephone Number:

Insurance Company that provided coverage for this claim:

Name:

Address:

Telephone Number: Policy Number:

_______________________________________________ __________________________ Signature Date _______________________________________________ __________________________ Printed Name Phone Number

NAME: _____________________________ DATE: ______________________________

Page 16 of 20

MEDICAL STAFF CONFLICT OF INTEREST STATEMENT

Medical Staff Member’s Name: ________________________________ Department: ______________________________________

Medical Staff Officer, Department or Committee Title, if any:

This statement is filed for (check one):

Credentialing purposes (new or renewal Annual or New Officer, Department Chief or Committee Chair Update

Key Definitions “Material financial interest” means

An employment, consulting, royalty, licensing, equipment or space lease, services arrangement or other financial relationship

An ownership interest

An interest that contributes more than 5% to a member’s annual income or the annual income of a family member

A position as a director, trustee, managing partner, officer or key employee, whether paid or unpaid

“Family member” means a spouse or domestic partner, children and their spouses, grandchildren and their spouses, parents and their spouses, grandparents and their spouses, brothers and sisters and their spouses, nieces and nephews and their spouses, parents–in-law and their spouses. Children include natural and adopted children. Spouses include domestic partners. “Ownership” includes ownership through sole proprietorships, stock, stock options, partnership or limited partnership shares, and limited liability company memberships. “Personal interests” mean those interests that arise out of a member’s personal activities or the activities of a family member. Disclosures of Material Financial and Personal Interests A. Ownership.

Do you (or does a family member) have an ownership interest in any company that provides goods or services to the Hospital, or otherwise does business with the Hospital?

No Yes, as follows:

Name of Person (self or family member)

Name of Company Percent of Ownership

Type of Services Provided by the Company

1.

2.

3.

(Use additional sheets as necessary)

NAME: _____________________________ DATE: ______________________________

Page 17 of 20

B. Compensation Arrangements . Do you (or does a family member) have an employment, consulting or other financial arrangement ( including, without limitation, an office or space lease, royalty or licensing agreement, or sponsored research agreement ) with a company that provides goods and services to the Hospital or otherwise does business with the Hospital?

No Yes, as follows:

Name of Person

(self or family member) Name of Company Describe the Compensation

Arrangement Dollar Value of Compensation

1.

2.

3.

(Use additional sheets as necessary)

C. Business Positions.

Are you (or is a family member) an officer, director, trustee, managing partner, officer or key employee of a company that provides goods and services to the Hospital or otherwise does business with the Hospital?

No Yes, as follows:

Name of Person (self or family member)

Name of Company Business Position or Title Dollar Value of Compensation (include

meeting stipends and travel reimbursement)

1.

2.

3.

(Use additional sheets as necessary) I certify that the information hereby submitted is accurate and complete as of the date stated below, and that I shall promptly provide written notice to the Medical Staff of any changes to the information, after such date.

_______________________________________________ ________________________ Signature of Medical Staff Member Date

NAME: _____________________________ DATE: ______________________________

Page 18 of 20

Exhibit A Memorandum of Understanding

Independent Physicians

The undersigned physician (hereinafter referred to as “you” or “your”) wishes to have access to and use of the Guam Regional Medical City “GRMC” network, which may include, as applicable, Intranet, Extranet, or audio/video/PDA/telecommunication devices, desktops and laptops (the “Network”). By granting you such access, you may be able to view or copy confidential or privileged patient-related information that is electronically stored and made available to health care professionals.

As a condition of receiving access to the Network, you acknowledge and agree as follows:

1. Information that you seek through the Network shall be limited solely to that of patients who are being cared for by both you and GRMC

2. You shall limit your use of the information obtained from the Network (the “Information”) solely to providing health care services to the patient to whom it relates. Where specifically permitted by GRMC, you and your business associate, as defined in the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), may also use the Information for obtaining payment for your services and for certain health care operations as permitted under HIPAA. You shall not use the Information for any other purpose nor disclose Information relating to a particular patient to any third party without the written authorization of said patient.

3. You agree to undertake a reasonable degree of care to protect the Information considering its confidential and privileged nature, which care shall not, in any event, be less than that required by law and by Network Usage Policy for Providers Not Employed by GRMC policy (“NUPP”), a copy of which is attached.

4. You have read and understand the NUPP, and agree that, in addition to the requirements herein, the NUPP also governs your access to and use of the Network. Any revisions to the NUPP, which may be necessary from time to time, will be readily available to you on the Network for your review.

5. Your Network user ID and password is unique to you and at no time shall you share with or otherwise disclose either of them to any other individual in your office or elsewhere. You agree to immediately report to GRMC the disclosure or loss of your user ID or password, or its inappropriate use.

6. If you or your medical practice is a covered entity under HIPAA, you acknowledge you are separately and solely responsible for protecting any protected health information while it is being viewed or if copied or downloaded using your User ID and password.

7. For the purpose of GRMC’s compliance with HIPAA, and security and integrity of the Network and the information therein, GRMC will electronically monitor, record and audit your Network activity. Nevertheless, you should not and cannot rely on such monitoring, recording, or auditing to electronically prohibit inappropriate use of your user ID or password by either you or another individual.

ACCEPTED AND AGREED TO:

I acknowledge I have read and understand this Memorandum of Understanding and NUPP and agreed to be bound by their requirements.

________________________________________________________ ___________________________________ Signature Date

NAME: _____________________________ DATE: ______________________________

Page 19 of 20

CONSENT TO PUBLICITY RELEASE

I authorize the Guam Regional Medical City to use my name, photo, materials produced for the program or presentation in program for the Guam Regional Medical City materials including but not limited to, educational resources, press releases, web-based publicity and other publicity materials (i.e., print advertisements, marketing brochures, promotional items, etc.)

_ Signature Date

**************************************** ☐ I DO NOT agree to release of photograph:

___________________________________________________ ______________________ Signature Date

NAME: _____________________________ DATE: ______________________________

Page 20 of 20

NOTICE OF APPLICATION FEE(S)

Please submit an application membership fee of $400.00

Please make check payable to:

GUAM REGIONAL MEDICAL CITY

In the amount of $400.00

Please include your check when you return your completed Application Questionnaire to the

Medical Staff Department.

Once payment has been received, processing of your application will begin.

The application fee is non-refundable.

(1) current - guam regional medical city · are pre-requisites for medical staff appointment. (1)...

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