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Medical Staff Application - CRNA

Page 1

Certified Registered Nurse Anesthesis

(CRNA)

Welcome

Thank you for applying to Nash Health Care, Inc. Attached please find a copy of our application

for you to complete. Please review the instructions and use them as a check off sheet to help

with all of the supporting documentation that is needed.

If you have any questions you may contact the Medical Staff Office at 252-962-8756 or via email

at

japinyan@nhcs.org

.

Please return your completed application to:

Nash Health Care Systems, Inc.

Medical Staff Services

2460 Curtis Ellis Drive

Rocky Mount, NC 27804

Please remember to include all supporting documents with the application.

An incomplete

application can delay the credentialing process.

After your application has been received in the medical staff office, it will be reviewed by the

medical director. Upon approval you will receive notification and information regarding

orientation.

Sincerely,

Jennifer

Jennifer A. Pinyan, RHIT

Medical Staff Coordinator

252-962-8756 (office)

252-962-3056 (fax)

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Medical Staff Application - CRNA

Page 2

Certified Registered Nurse Anesthesis

CRNA

TABLE OF CONTENTS

I.

INSTURCTION SHEET

II.

MEDICAL STAFF APPLICATION

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Medical Staff Application - CRNA

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INSTRUCTIONS

Before submitting the Application, make sure you have:

Included an answer in

all

spaces. Indicate “N/A”, if the question is not applicable.

Sign and date privilege form(s).

Signed and dated the last page of the Application.

Before submitting the Application, make sure you have enclosed the following,

if applicable

:

Copy of the provider’s original state(s) license(s) and current registration.

Copy of the face sheet of your current professional liability insurance policy, indicating by name, provider(s) covered

coverage amounts, effective date, expiration date, and policy number. Minimum limits of $1,000,000 and $3,000,000.

(unless covered through hospital policy)

Copy of NPI verification letter

Copy of AANA certification/recertification.

Copy of verification of certification/recertification by the NCBON

Copy of ACLS/PALS certification

Current PPD/TB skin results.

Copy of diploma from anesthesia training program

Copy of Curriculum Vitae (CV) or work history after graduation

Provide a listing of CME’s obtained within the last 2 years.

Copy of driver’s license

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Medical Staff Application - CRNA

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Medical Staff Application

A.

DEMOGRAPHIC AND PERSONAL DATA:

Name of Applicant: __________________________________________________________________________________

Last Name First Name Middle Name Maiden

Home Address_________________________________________________________________________ Street City Zip

Home Telephone #:__________________________ Pager #:_________________________ E-mail:____________________________________ Mobile #:________________________

Date of Birth: _____/_____/_____ Place of Birth: __________________________________________________________ Social Security Number: _____-_____-______ Sex:  

Language(s) spoken, including sign language: ___________________________

Personal Information: Marital Status: Married Single Divorced If married, please provide Name of Spouse: ____________________________________ Type of Appointment Requested:

_____CRNA – Full time _____CRNA – Part time ____CRNA - PRN

When would you desire to begin work? _________________________

Name of Practice/Group: Nash Health Care – Anesthesiology Department

===============================================================================================

NPI Number_____________________________ Medicare/Medicaid Number _______________/_____________ License Number ______________________________________________________ Exp. Date____________________

(Attach copy to application)

AANA Number ______________________________________________________ Exp. Date____________________

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Medical Staff Application - CRNA

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A.

DEMOGRAPHIC AND PERSONAL DATA (Continued)

Provide the following information for each state in which you are currently or were previously licensed to practice (If not enough space please attach additional sheet):

STATE DATE OF LICENSE LICENSE NUMBER STATUS:

Active,Inactive,Suspended

EXPIRATION DATE

/ /

/ /

/ /

/ /

PLEASE ATTACH A COPY OF EACH STATE LICENSE CERTIFICATE

List all hospitals where you currently have privileges and indicate the type and status of those privileges:

(Type: active, admitting, associate, consulting, courtesy. Status: pending, provisional, suspended, temporary, visiting) Hospital Department and Status of Privilege Dates of Affiliation

_________________________________ _________________________________ ______________________

(Primary admitting facility)

_________________________________ _________________________________ ______________________ _________________________________ _________________________________ ______________________ _________________________________ _________________________________ ______________________

B.

EDUCATION AND PRACTICE HISTORY

Professional School Attended:

Institution ______________________________________________________________________________________ Address ________________________________________________________________________________________

________________________________________________________________________________________

City State Zip

Degree _____________________________________________________ From ____/____/____ To ____/____/_____

Internship:

Institution ______________________________________________________________________________________ Address ________________________________________________________________________________________

________________________________________________________________________________________

City State Zip

Specialty___________________________________________________ From ____/____/____ To ____/____/_____

Residency:

Institution ______________________________________________________________________________________ Address ________________________________________________________________________________________

________________________________________________________________________________________

City State Zip

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Medical Staff Application - CRNA

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B.

EDUCATION AND WORK HISTORY - (Continued)

Other Residency/Fellowship - (specify)

Institution ______________________________________________________________________________________ Address ________________________________________________________________________________________

________________________________________________________________________________________

City State Zip

Specialty____________________________________________________ From ____/____/____ To ____/____/_____ During your internship, residency, fellowship or teaching appointment:

a. Where you ever disciplined, suspended, place upon probation, formally reprimanded, or asked to resign? YES  NO 

b. Did you have an interruption in your training for 30 or more consecutive days? YES  NO 

List work history since beginning of professional school; please be specific. (If not enough space, please attach additional sheet)

FROM / TO ________________________________________________________________________ ____ / ___ ____ / ___

Current practice (Month / Year) (Month / Year)

________________________________________________________________________ ____ / ___ ____ / ___

Previous practice (Month / Year) (Month / Year)

_____________________________________________________________________ ____ / ___ ____ / ___

Previous practice (Month / Year) (Month / Year)

________________________________________________________________________ ____ / ___ ____ / ___

Previous practice (Month / Year) (Month / Year)

________________________________________________________________________ ____ / ___ ____ / ___

Previous practice (Month / Year) (Month / Year)

List other training and/or education within the last three years, if applicable.

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Have you ever been involved in a malpractice claim or lawsuit?

(This includes claims, lawsuits, and settlements in or out of court, and arbitration or medication proceedings, in any state.)

Claimant’s name: _______________________________________ Age: ________ Date of Loss: _____________

Insurance defending you: ______________________________________________________________________ Was lawsuit filed? If yes, when (month/year): _______________________

Status:

Open

Closed

Dismissed

Settled

Trial Amount of Payment: _____________

Was payment a settlement or award of damage? ____________________________________

Allegations: _________________________________________________________________________________ ___________________________________________________________________________________________ Description of treatment: _______________________________________________________________________

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Medical Staff Application - CRNA

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Please circle yes or no for the following questions. Please provide details on the attached Supplemental Form for any questions to which you answer “yes.”

YES NO

1. Has your employment, medical staff appointment, or clinical privileges every been voluntarily or involuntarily suspended, diminished, revoked, refused, relinquished, or limited at any hospital or other health care facility?

Y N

2. Have you ever withdrawn your application for appointment or reappointment or resigned from the medical staff before a decision was made by the hospital or governing board?

Y N

3. Have you ever been suspended, sanctioned, or otherwise restricted from participating in any private, federal, or state health insurance program (Medicare, Medicaid, BCBS

Y N

4. Have you ever been the subject of an investigation by any private, federal or state agency concerning your participation in any private, federal or state health insurance program?

Y N

5. Have you ever been subject to probationary conditions or have proceedings to those ends ever been instituted or recommended by a committee or governing body of any hospital, health care institution or P.R.O?

Y N

6. Has your request for any specific clinical privilege(s) been denied or granted with limitations (aside from ordinary requirements of proctorship) or has such a denial or limitation ever been recommended by a committee or governing body?

Y N

7. Have you ever been denied membership or renewal thereof, or been subject to disciplinary proceedings in any professional organization?

Y N

8. Has your license to practice your profession in any jurisdiction ever been surrendered, suspended, revoked, denied or subject to probationary conditions?

Y N

9. Have you ever been the subject of any licensure authority investigation or disciplinary action in any jurisdiction? Y N

10. Has your Drug Enforcement Agency or other controlled substance authorization ever been suspended, revoked, reduced or not renewed?

NA NA

11. Have you ever voluntarily relinquished any medical staff membership, clinical privilege(s), medical organization or professional society membership, professional license(s) or narcotics registration?

Y N

12. Have you ever been convicted of any misdemeanor other than minor traffic violations, felony or have been

named as a defendant in any criminal proceeding Y N 13. Have you ever been treated for alcohol or other substance abuse or do you have a history of drug or

alcohol abuse?

Y N

14. Has any aspect of your care ever been investigated by another hospital/facility in which you held clinical privileges?

Y N

15. Do you presently have a physical or mental health condition that may affect your ability to exercise the clinical privileges requested or would require an accommodation in order for you to exercise the privileges requested safely and competently?

Y N

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Medical Staff Application - CRNA

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SUPPLEMENTAL FORM

Provider Name:______________________________________________

Please explain:__________________________________________________________________________________ _ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________
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Medical Staff Application - CRNA

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MEDICAL STAFF APPLICATION PAST AFFILIATIONS Applicant’s Name:

PAST AFFILIATIONS: List in chronological order all past institutional/practice affiliations since the completion of your postgraduate education. This includes, without limitation, all hospitals, businesses, charitable organizations, educational institutions, corporations, military organizations or government agencies, (please include a copy of orders or discharge papers). Complete addresses must be included. If more space is needed, attach an additional sheet.

If the foregoing chronology does not account for all time periods since the completion of your postgraduate education, please describe your whereabouts and/or activities during such periods.

Facility/Practice Name: ______________________________________________________________________ Mailing Address: _____________________________________________________________________________ Type of Privileges: _____________________________________________________________________________ Phone:___________________________Fax:__________________________e-mail: _________________________ Contact Name (if available): _____________________________________________________________________ Dates of Appointment: From __________________________ To:__________________________

Facility/Practice Name: _______________________________________________________________________ Mailing Address: _____________________________________________________________________________ Type of Privileges: _____________________________________________________________________________ Phone:___________________________Fax:__________________________e-mail: _________________________ Contact Name (if available): ____________________________________________________________________ Dates of Appointment: From __________________________ To:__________________________

Facility/Practice Name: _______________________________________________________________________ Mailing Address: _____________________________________________________________________________ Type of Privileges: _____________________________________________________________________________ Phone:___________________________Fax:__________________________e-mail: _________________________ Contact Name (if available): ______________________________________________________________________ Dates of Appointment: From __________________________ To:__________________________

Facility/Practice Name: ________________________________________________________________________ Mailing Address: _____________________________________________________________________________ Type of Privileges: _____________________________________________________________________________ Phone:___________________________Fax:__________________________e-mail:_________________________ Contact Name (if available): _____________________________________________________________________ Dates of Appointment: From __________________________ To:__________________________

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Medical Staff Application - CRNA

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MEDICAL STAFF APPLICATION

REFERENCES

Applicant’s Name: Please refer to the facility specific requirements regarding peer references.

List 2 personal and 3 professional references that have current personal knowledge of and can evaluate your current clinical ability, ethical character, health status and ability to work cooperatively with others. The named peer references must have acquired their knowledge through recent observation of your professional practice over a reasonable period of time. None of the peer references should be related to you by family. A confidential questionnaire will be sent to these individuals.

PERSONAL

Name:__________________________________________________Title:________________________________ Group/Practice or Affiliation Name:_______________________________________________________________ Dates of Association_______________ through________________

____________________________________________________________________________________________

PO Box Street City State Zip

Telephone:_______________________ Fax:_______________________ e-mail_______________________

Name:__________________________________________________Title:________________________________ Group/Practice or Affiliation Name:_______________________________________________________________ Dates of Association_______________ through________________

____________________________________________________________________________________________

PO Box Street City State Zip

Telephone:_______________________ Fax:_______________________ e-mail_______________________ PROFESSIONAL

Name:__________________________________________________Title:________________________________ Group/Practice or Affiliation Name:_______________________________________________________________ Dates of Association_______________ through________________

____________________________________________________________________________________________

PO Box Street City State Zip

Telephone:_______________________ Fax:_______________________ e-mail_______________________

Name:__________________________________________________Title:________________________________ Group/Practice or Affiliation Name:_______________________________________________________________ Dates of Association_______________ through________________

____________________________________________________________________________________________

PO Box Street City State Zip

Telephone:_______________________ Fax:_______________________ e-mail_______________________

Name:__________________________________________________Title:________________________________ Group/Practice or Affiliation Name:_______________________________________________________________ Dates of Association_______________ through________________

____________________________________________________________________________________________

PO Box Street City State Zip

Telephone:_______________________ Fax:_______________________ e-mail_______________________

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Medical Staff Application - CRNA

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MEDICAL STAFF APPLICATION

Applicant’s Name: _______________________________ Facility Name: _____________________________________

Acknowledgements and Release

I fully understand that any significant misstatements in or omissions from this application constitute cause for denial of appointment or cause for summary dismissal from the medical staff. All information submitted by me in this application is current and true to my best knowledge and belief.

In making this application for privileges and appointment to the medical staff of this facility, I acknowledge that I have received and read the Bylaws, Rules and Regulations of the medical staff of this facility, and that I am familiar with the principles, standards and ethics of The Joint Commission Accreditation of Healthcare Organizations and the national, state and local associations that apply to and govern my specialty and/or profession. I agree to be bound by the terms thereof if I am granted membership or clinical privileges, and I further agree to be bound by the terms thereof without regard to whether or not I am granted membership or clinical privileges in all matters relating to the consideration of my application for appointment to the medical staff. I acknowledge that the provisions of said Medical Staff Bylaws relating to confidentiality and release from liability are express conditions to my application for, and acceptance of, Medical Staff membership and the continuation of such membership and to my exercise of clinical privileges. I further agree and abide by such facility and staff policies and staffrules and regulations as may be from time to time enacted. I agree to maintain the confidentiality of all patient information, peer review information and all other information to which I have access. I further agree to provide treatment and continuous care and supervision of patients for whom I have responsibility, and timely adequate completion of record documentation.

By applying for appointment to the medical staff, I hereby signify my willingness to be interviewed in regard to my application and authorize the facility, its medical staff and their representatives/designees to consult with administrators and members of the medical staffs of other facilities or institutions with which I have been associated and with others (including past and present malpractice carriers) who may have information bearing on my professional competence, character and ethical qualifications. I hereby further consent to the inspection by the facility, its medical staff and its representatives/designees of all records and documents that may be material to an evaluation of my professional qualifications and competence to carry out the clinical privileges requested, as well as my moral and ethical qualifications for staff membership. I hereby release from liability all representatives/designees of the facility and its medical staff for their acts performed in good faith and without malice in connection with evaluating my application, credentials and qualifications. I further hereby release from liability any and all individuals and organizations that provide information to the facility or its medical staff, in good faith and without malice, concerning my professional competence, ethics, character, personal health information and other qualifications for staff appointment and clinical privileges. I hereby consent to the release of such information.

I hereby further authorize and consent to the release of information by this facility or its medical staff/designees to other facilities, medical associations and other interested persons on request regarding any information the facility and the medical staff may have concerning me as long as such release of information is done in good faith and without malice, and I hereby release from liability this facility and its staff and/or designees for so doing.

I understand and agree that I, as an applicant for medical staff membership, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, personal health information and other qualifications and for resolving any questions about such qualifications.

I have not requested privileges for any procedures for which I am not qualified. Furthermore, I realize that certification by a board does not necessarily qualify me to perform certain procedures. However, I believe that I am qualified to perform all procedures/privileges I have requested.

________________________ ____________________________________

Date Signature

The facility will treat this application and any information secured in connection therewith in strict confidence and will employ all reasonable safeguards to protect the Applicant’s privacy.

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Medical Staff Application - CRNA

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Privilege Request

Certified Registered Nurse Anesthetist

Name: __________________________________________ Initial Appointment 

Reappointment 

Check area of coverage:

Labor & Delivery

NGH/NDH

Qualifications:

Graduate of approved nursing program with a Bachelor of Science in Nursing or another appropriate

baccalaureate degree from an approved nursing program

Graduate from a nurse anesthesia educational program accredited by the AANA Council on

Accreditation of Nurse Anesthesia Educational programs.

Recognized by the AANA Council for Certification in Nurse Anesthetists with verification of

certification/recertification by the NCBON.

Current licensure to practice as a Registered Nurse in North Carolina

Professional liability insurance coverage issued by employer or recognized company and in an amount

equal to or greater than the limits established by the governing board

BCLS Certification, recertification required every 2 years

ACLS Certification; recertification required every 2 years

NRP Certification; recertification required every 2 years (For L & D)

Demonstrate the ability to understand, communicate and react effectively and appropriately to the needs

of surgical or obstetric (For L & D) patients. Be able to demonstrate clinical competence per the job’s

Skills Checklist before being allowed to perform independently.

Experience:

CRNAs with required credentials are eligible to apply. Evidence of current experience will be reviewed.

Reappointment requirements:

Current demonstrated competence and an adequate volume to consist of a minimum of 850 hours of

practice over a two year recertification period.

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Medical Staff Application - CRNA

Page 13

Privilege Request

Certified Registered Nurse Anesthetist

Page 2

Name: _________________________________________ Initial Appointment 

Reappointment 

Scope of Practice for CRNA

Performing and documenting a pre-anesthetic assessment and evaluation of the patient.

Administering the anesthetics, adjuvant drugs, accessory drugs and fluids necessary to induce and

manage the anesthetic, to maintain the patient’s physiologic homeostasis, and to correct abnormal

responses to the anesthesia or surgery

Applying or inserting appropriate noninvasive and invasive monitoring modalities for continuous

evaluation of the patient’s physical status

Managing a patient’s airway and pulmonary status using current practice modalities

Managing emergence and recovery from anesthesia with medications, fluids, or ventilator support in

order to maintain homeostasis; to provide relief from pain and anesthesia side effects; or to prevent

or manage complications

Releasing or discharging patients from the post-anesthesia care area and providing post-anesthesia

follow-up evaluation and care

Implementing acute pain management modalities

Respond to emergency situations as needed

Clinical education of student register nurse anesthetists’ (SRNAs) who are enrolled in a nurse

anesthesia educational program accredited by the Council on Accreditation of Nurse Anesthesia

Educational Programs (COA).

CRNA Privileges

Pre-anesthetic assessment

Requesting laboratory/diagnostic studies

Pre-anesthetic medication

General anesthesia and adjuvant drugs

Regional anesthesia techniques

-Epidural (For L & D)

-Local infiltration

□-

Bier Block

□-

Topical

Sedation techniques

Cardiopulmonary resuscitation management

Invasive and noninvasive monitoring

Airway management techniques

Mechanical ventilation/oxygen therapy

Fluid, electrolyte, acid-base management

Blood, blood products, plasma expanders

Peripheral intravenous/arterial catheter placement

Acute pain therapy

Post-anesthesia care/discharge

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Medical Staff Application - CRNA

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Privilege Request

Certified Registered Nurse Anesthetist

Page 3

Other

_____________________________

_____________________________

CRNAs are supervised by a physician. Clinical Ongoing Performance review is completed by Anesthesiology

with appointment/reappointment applications reviewed by the Department Chairman. Written evaluations of

the CRNAs performance are to be submitted to the Medical Staff office.

Acknowledgement of practitioner

I have requested only those services for which, by education, training, current experience, and demonstrated

performance, I am qualified to perform and which I wish to exercise at Nash Health Care Systems, Inc.

I understand that, in exercising any specific services granted and in carrying out the responsibilities assigned to

me, I am constrained by any hospital and medical staff policies and rules applicable generally and any applicable

to the particular situation. Any restriction on the specified services granted to me is waived in an emergency

situation, and in such situation, my actions are governed by the applicable section of the policies governing

allied health professionals.

References

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