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Fields
Pre-Application Form
Name
*
Prefix
*
First Name
*
Middle Name
*
Last Name
*
Birthdate
*
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Office Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Office Phone
Office Fax
Residential Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Home Telephone
*
Cell
Beeper
Email
*
1. Please indicate your clinical specialty as well as any areas in which you may wish to request clinical privileges.
2. Do you plan to establish, or have you established an office on the Westbank of Jefferson, Orleans, Plaquemines, or St. Charles Parishes?
Yes
No
3. If so, where?
4. In chronological order, please list all hospitals at which you have held clinical privileges during the last five years.
Hospital, address, and appointment dates
5. Who will provide call coverage for you?
6. Are you employed by any entity? If so, please identify.
7. Have you ever had any past adverse licensure action against you by any state or federal licensing board?
Yes
No
8. Do you have any of the following?
*
8. Do you have any of the following?
Yes
No
Any felony conviction?
8. Do you have any of the following?: Any felony conviction? (Yes)
Any felony conviction? (No)
Conviction of any Medicare, Medicaid, or insurance fraud or exclusion from such programs?
Conviction of any Medicare, Medicaid, or insurance fraud or exclusion from such programs? (Yes)
Conviction of any Medicare, Medicaid, or insurance fraud or exclusion from such programs? (No)
Any conviction of felony or misdemeanor related to professional practice, reimbursement or controlled substance violations?
Any conviction of felony or misdemeanor related to professional practice, reimbursement or controlled substance violations? (Yes)
Any conviction of felony or misdemeanor related to professional practice, reimbursement or controlled substance violations? (No)
9. Have your medical staff privileges or appointments ever been modified, denied, revoked or terminated for reasons related to professional competency or conduct or during an investigation into competency or conduct?
Yes
No
10. What category do you intend to apply for?
*
Active
Courtesy
Consulting
Upload Documents
The Pre-Application Form MUST be returned with copies of the following documents:
Current license(s) to practice medicine
*
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Narcotics registration certificate
*
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Professional liability insurance policy and certificate of coverage from insurance carrier
*
No File Chosen
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Medical school diploma or ECFMG certificate
*
No File Chosen
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Evidence of board certification status or satisfactory completion of ABMS approved residency
*
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A curriculum vitae
*
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A current photograph
*
No File Chosen
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A case log – to include number of procedures performed in the past two (2) years and associated outcomes
*
No File Chosen
File uploads may not work on some mobile devices.
Any misrepresentation, misstatement, or omission during the application process, whether intentional or not, is cause for the immediate cessation of the processing of this application and no further processing shall occur. Upon subsequent discovery of such misrepresentation, misstatement, or omission, the entity to which I am applying may deem any relationship they have with me to be automatically relinquished, including but not limited to medical staff appointment, clinical privileges, participating provider status or contracts. In either situation, there shall be no entitlement to any hearing or appeal rights that are contained in the entities bylaws, policies, or contracts. I request an application for appointment to the medical staff.
*
I accept
Signature
*
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Date
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I recognize that membership on the Medical/Dental Staff of this Hospital is contingent upon professional competence and ethical practice in keeping with the qualifications, standards and requirements set forth in the Medical/Dental Staff Bylaws, Rules and Regulations. I further recognize that the Medical/Dental Staff of this Hospital must periodically reevaluate my professional competence and qualifications and make appropriate recommendations to the Governing Body. Accordingly, it may be necessary for the Medical Staff to request of other persons and institutions, including medical schools, hospitals, medical societies, professional liability insurance carriers, individual practitioners and other appropriate sources information regarding my qualifications and performance. Additionally, I understand that the Hospital and Medical/Dental Staff may receive similar requests, from other legitimately interested organizations and institutions, as an applicant and/or member of this Medical/Dental Staff. I understand that all evaluations, inquiries, and responses to inquiries regarding my professional competence and qualifications shall be carried out in a professional and ethical manner, with due regard for appropriate confidentiality of the information at issue.
*
I accept
I also recognize that I will be afforded the fair hearing procedure prescribed by the Medical/Dental Staff Bylaws in the event that action on this application, or with respect to my privileges, is adverse. Recognizing these facts, I specifically agree and consent to the following: (1.) To appear if requested before Medical Staff officers, department and service chiefs, and Medical Staff Committees for interviews or inquiries regarding this application for reappointment. (2.) To assist, in every way possible, this Medical Staff and its representatives, in gathering the information necessary to determine my qualifications. In this regard, I recognize that I have the burden of resolving any reasonable doubts about my qualifications for staff membership and the requested privileges. (3.) To the dissemination of information including all Medical Staff and medical records pertaining to my professional qualifications between this Hospital and its Medical Staff and other persons, hospitals, medical staff, professional societies, training programs, professional associations, professional liability insurance companies, and licensing authorities in jurisdictions in which I have trained, resided, or practiced, for the present and continuing evaluation of my professional training, experience, character, conduct and judgment; (4.) To be bound by the terms of the Medical Staff and Hospital Bylaws in all matters relating to the consideration of this application, regardless of whether I am granted Medical Staff membership and the privileges sought. In this opportunity to review the Medical Staff Bylaws, Rules and Regulations, and any Hospital Bylaws or rules and policies which may pertain.
*
I accept
I pledge to maintain an ethical practice, to provide for continuous care of all my patients, and to acknowledge and abide by any Medical Staff Bylaws requirements for release and immunity from civil liability. I further release from liability any persons or entities which request or provide information in furtherance of the above-described purposes, whether or not such release is specifically required by pertinent bylaws, to the fullest extent established by applicable statutes regulations and judicial decisions. I fully understand that any significant misstatement(s) in or omission from these applications will constitute cause for cessation of processing said application(s) for requested membership and medical privileges or cause for revocation of membership of privileges. I hereby affirm that the information furnished by me to the Medical Staff is true to the best of my knowledge and is furnished in good faith. I have received, read, and agree to abide by the Medical/Dental Staff Bylaws, Rules & Regulations and any other hospital policy that may be in effect from time to time.
*
I accept
Signature
*
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If you are you applying to multiple LCMC Health facilities, please be advised that you must complete a pre-application for each facility at their independent website.
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