Form 0917-0009-1 Application for Medical Staff Appointment and/or Privile

FORM APPROVED
OMB Approval No. 0917–0009
Expiration Date: 6/30/2016
Estimated response time below.

Manual Exhibit 3-1-A
Page 1 of 20

INDIAN HEALTH SERVICE
Application for Medical Staff Appointment and/or Privileges
INSTRUCTIONS
This application form must be typed or clearly printed using black ink only. Provide all
requested information. If more space is needed, attach additional sheets.
Do not submit curriculum vitae or resume in lieu of completing this application form.
“Refer to CV” will not be accepted, and the application form will be returned to you for
completion.
So that it is understood that you did not intentionally omit an item, type or print N/A (Not
Applicable) beside those items that do not apply to you, unless instructions indicate
otherwise.
Failure to complete this form in its entirety will delay the credentialing process and your
appointment to the Medical Staff.
Misrepresentations, inaccuracies, or falsification of information can be grounds for
termination of Medical Staff appointment and associated clinical privileges, and may be
subject to the reporting requirements of the National Practitioner Data Bank.
Please attach to Page 1 of this application form a copy of government-issued photo
identification (for example, a driver’s license, passport, or military ID).

ESTIMATED AVERAGE BURDEN TIME PER RESPONSE
Public reporting burden for this collection of information is estimated to average 60 minutes per
response including time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An agency
may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to: Indian Health Service, 801 Thompson Avenue, TMP Suite 450, Rockville, MD 20852,
ATTN: PRA (0917–0009). Please do not send this form to this address.

TN 2008-19
(11/19/2008)

Manual Exhibit 3-1-A
Page 2 of 20

Indian Health Service
Application for Medical Staff Appointment and/or Privileges
IMPORTANT: All parts of this application must be completed. No part of this application may be
completed by writing “See CV.”
Area applying to:

Hospital/Clinic:

DEMOGRAPHIC INFORMATION
Name (Last, First, Middle):

Degree:

Other Names Used:

Specialty:

Email Address:

Office Address:

Home Address:

City:

State:

Zip:

Office Phone:

City:

State:

Zip:

Home Phone:

Date of Birth:

Place of Birth:

Languages Spoken:

Social Security Number:
Country of Citizenship:

PROFESSIONAL EDUCATION
Please include a copy of diploma. If more than TWO schools, identify and explain on separate sheet
1. Name of Institution:

Dates Attended (mm/yyyy):

Address:

City:

Degree Obtained:

Honors:

State:

Did you successfully complete this program?
Yes

No (if no, attach an explanation)

Were you the subject of any disciplinary action during your attendance at this institution?
No

TN 2008-19
(11/19/2008)

Yes (if yes, attach an explanation)

Zip:

Manual Exhibit 3-1-A
Page 3 of 20
IMPORTANT: All parts of this application must be completed. No part of this application may be
completed by writing “See CV.”
PROFESSIONAL EDUCATION (Continued)
2. Name of Institution:

Dates Attended (mm/yyyy):

Address:

City:

Degree Obtained:

Honors:

State:

Zip:

Did you successfully complete this program?
Yes

No (if no, attach an explanation)

Were you the subject of any disciplinary action during your attendance at this institution?
No

Yes (if yes, attach an explanation)

ECFMG (Foreign medical graduates) Include copy of certificate
Certificate Number:

Date Issued (mm/yyyy):

Serial Number for ECFMG:

INTERNSHIP If more than one program, use separate sheet
Name of Institution:

Dates Attended (mm/yyyy):

Address:

City:

Type of Internship:

Rotating

State:

Zip:

Straight (If straight, list discipline:

)

Did you successfully complete this program?
Yes

No (if no, attach an explanation)

Were you the subject of any disciplinary action during your attendance at this institution?
No

Yes (if yes, attach an explanation)

RESIDENCY Please include copy of certificate(s). If more than two programs, use separate sheet
1. Name of Institution:

Program:

Address:

City:

Dates Attended (mm/yyyy):
State:

Did you successfully complete this program?
Yes

No (if no, attach an explanation)

Were you the subject of any disciplinary action during your attendance at this institution?
No

TN 2008-19
(11/19/2008)

Yes (if yes, attach an explanation)

Zip:

Manual Exhibit 3-1-A
Page 4 of 20
IMPORTANT: All parts of this application must be completed. No part of this application may be
completed by writing “See CV.”
RESIDENCY (Continued)
2. Name of Institution:

Program:

Address:

Dates Attended (mm/yyyy):

City:

State:

Zip:

Did you successfully complete this program?
Yes

No (if no, attach an explanation)

Were you the subject of any disciplinary action during your attendance at this institution?
No

Yes (if yes, attach an explanation)

FELLOWSHIP Please include copy of certificate. If more than one program, use separate sheet.
Name of Institution:

Program:

Address:

Dates Attended (mm/yyyy):

City:

State:

Zip:

Did you successfully complete this program?
Yes

No (if no, attach an explanation)

Were you the subject of any disciplinary action during your attendance at this institution?
No

Yes (if yes, attach an explanation)

TEACHING EXPERIENCE/FACULTY APPOINTMENT List current and previous appointments.
If more than two programs, use separate sheet
Position/Rank:
Dates of Affiliation (mm/yyyy):
1. Name of Institution:
Address:

City:

Phone:

Fax:

State:

Zip:

Program Director:

Were you the subject of any disciplinary action during your attendance at this institution?
No

Yes (if yes, attach an explanation)

2. Name of Institution:

Position/Rank:

Address:

Phone:

Dates of Affiliation (mm/yyyy):
City:

Fax:

State:

Program Director:

Were you the subject of any disciplinary action during your attendance at this institution?
No

TN 2008-19
(11/19/2008)

Yes (if yes, attach an explanation)

Zip:

Manual Exhibit 3-1-A
Page 5 of 20
IMPORTANT: All parts of this application must be completed. No part of this application may be
completed by writing “See CV.”
BOARD CERTIFICATION
1. Name of Board:

Certification Dates (mm/yyyy):

Primary

Secondary

2. Name of Board:

Certification Dates (mm/yyyy):

Primary

Secondary

3. Name of Board:

Certification Dates (mm/yyyy):

Primary

Secondary

If not certified, have you applied for certification examination?
If no, do you intend to apply for certification?

Yes

No (if no, attach an explanation)

Yes Date:

No

PROFESSIONAL LICENSURE If more space is needed, please list on separate sheet.
*If limits or restrictions, please explain on separate sheet.
1. State:

License Number:

Active
Inactive

2. State:

License Number:

Active
Inactive

3. State:

License Number:

Active
Inactive

State CDS Number:

Expiration Date (mm/yyyy):

Expiration Date
(mm/yyyy):

Limits/Restrictions:

Expiration Date
(mm/yyyy):

Limits/Restrictions:

Expiration Date
(mm/yyyy):

Limits/Restrictions:

Limits/Restrictions:

Yes*

No

Yes*

No

Yes*

No
No

Yes*

NATIONAL PROVIDER IDENTIFICATION (NPI) Number:
NARCOTICS REGISTRATION CERTIFICATES *If limits or restrictions, please explain on separate sheet.
DEA Number:

Expiration Date (mm/yyyy):

Limits/Restrictions:

No

Yes*

PROFESSIONAL REFERENCES Please list names of two (2) individuals who have personal knowledge (within
the last 12 months) of your current clinical abilities, ethical character, and interpersonal skills. Receipt of this
information is required before action can be taken on your application. For those in training, one reference must
be from the Director of the training program. For all other applicants, one letter must be from the Chief of Staff or
Departmental Chairperson from each hospital, where the applicant is on the active clinical staff
Name:
Specialty:
Address:

Email Address:

TN 2008-19
(11/19/2008)

Title:
Relationship:

Years Known:

Daytime Phone:

Evening Phone:

City:

State:

Fax:

Zip:

Manual Exhibit 3-1-A
Page 6 of 20
IMPORTANT: All parts of this application must be completed. No part of this application may be
completed by writing “See CV.”
PROFESSIONAL REFERENCES (Continued)
Name:

Title:

Specialty:

Relationship:

Address:

Email Address:

Years Known:

Daytime Phone:

Evening Phone:

City:

State:

Zip:

Fax:

AFFILIATIONS/WORK HISTORY List in chronological order, beginning with most current, all practice history
(past and present) that has occurred since completion of medical or professional school. List hospitals,
ambulatory centers, and medical offices where you have ever had an affiliation or where you have an application
in process. Include all work engagements (including employment, self-employment, and service as an
independent contractor). Indicate staff status (Active, Courtesy, Provisional, Temporary, etc.) Do not duplicate
fellowship or internship/residency information previously reported. Enter additional affiliations on a separate
sheet of paper and attach to application. If there is any gap greater than 30 days in chronology, explain in next
section.
1. Organization Name:

Title/Professional Occupation:

Street Address:

Dates of Affiliation Reason for Leaving:
(mm/yyyy):

City:

Phone:

Fax:

State:

Staff Status:

Zip:

Supervisor:

Were you the subject of any disciplinary action during your attendance at this institution?
No

Yes (if yes, attach an explanation)

2. Organization Name:

Title/Professional Occupation:

Street Address:

Phone:

Dates of Affiliation Reason for Leaving:
(mm/yyyy):

City:

Fax:

State:

Staff Status:

Supervisor:

Were you the subject of any disciplinary action during your attendance at this institution?
No

TN 2008-19
(11/19/2008)

Yes (if yes, attach an explanation)

Zip:

Manual Exhibit 3-1-A
Page 7 of 20
IMPORTANT: All parts of this application must be completed. No part of this application may be
completed by writing “See CV.”

AFFILIATI
AFFILIATIO
ONS/WO
NS/WOR
RK HISTORY
HISTORY (Con
(Continued).
tinued).
3. Organization Name:

Title/Professional Occupation:

Street Address:

Dates of Affiliation Reason for Leaving:
(mm/yyyy):

City:

Phone:

Fax:

State:

Staff Status:

Zip:

Supervisor:

Were you the subject of any disciplinary action during your attendance at this institution?
No

Yes (if yes, attach an explanation)

4. Organization Name:

Title/Professional Occupation:

Street Address:

Dates of Affiliation Reason for Leaving:
(mm/yyyy):

City:

Phone:

Fax:

State:

Staff Status:

Zip:

Supervisor:

Were you the subject of any disciplinary action during your attendance at this institution?
No

Yes (if yes, attach an explanation)

5. Organization Name:

Title/Professional Occupation:

Street Address:

Dates of Affiliation Reason for Leaving:
(mm/yyyy):

City:

Phone:

Fax:

State:

Staff Status:

Zip:

Supervisor:

Were you the subject of any disciplinary action during your attendance at this institution?
No

Yes (if yes, attach an explanation)

6. Organization Name:

Title/Professional Occupation:

Street Address:

Phone:

Dates of Affiliation Reason for Leaving:
(mm/yyyy):

City:

Fax:

State:

Staff Status:

Supervisor:

Were you the subject of any disciplinary action during your attendance at this institution?
No

TN 2008-19
(11/19/2008)

Yes (if yes, attach an explanation)

Zip:

Manual Exhibit 3-1-A
Page 8 of 20
IMPORTANT: All parts of this application must be completed. No part of this application may be
completed by writing “See CV.”
AFFILIATIONS/WORK HISTORY (Continued).
7. Organization Name:
Title/Professional Occupation:

Street Address:

Phone:

Dates of Affiliation Reason for Leaving:
(mm/yyyy):

City:

Fax:

State:

Staff Status:

Zip:

Supervisor:

Were you the subject of any disciplinary action during your attendance at this institution?
No

Yes (if yes, attach an explanation)

EXPLANATION OF WORK HISTORY GAPS Any time period or gaps greater than 30 days since graduation
from professional school, which are not explained in the application, must be addressed here. If the application is
found to have any unexplained time periods or gaps, the application will not be processed and will be returned to
the applicant as incomplete.
Dates
(mm/dd/yyyy)

Person who can verify
(phone/email)

Explanation of work history gap

Continuing Professional Education
Describe topics, sources, and dates of all continuing education you have completed in
the past two years on a separate sheet.
EMERGENCY PROCEDURE CERTFICATION
Current training and certification in the following is highly desirable for all professionals involved in direct patient
care. Please check the appropriate box for any certification you hold.
Title
Basic Life Support
Advanced Cardiac Life Support
Advanced Trauma Life Support
Advanced Life Support for Obstetrics
Pediatric Advanced Life Support
Neonatal Resuscitation Program

TN 2008-19
(11/19/2008)

Expiration Date

Manual Exhibit 3-1-A
Page 9 of 20
IMPORTANT: All parts of this application must be completed. No part of this application may be
completed by writing “See CV.”
MALPR
MALPRA
ACTI
TICE
CE COVE
COVERA
RA
RAG
GE List cu
curre
rre
rren
nt and pa
past
st insuran
insurancce carri
carrie
ers d
du
uri
ring
ng the past 10 years.
If additional space is ne
nee
eded, use sep
separate
arate she
shee
et.
Present Carrier:

Agent Name:

Address:

Policy Number:

City:

State:

Zip:

Amount of Coverage:

Past Carrier:

Agent Name:

Address:

Policy Number:

City:

State:

Zip:

Amount of Coverage:

Coverage Dates (mm/yyyy):

Coverage Dates (mm/yyyy):

PROFESSIONAL PRACTICE QUESTIONS
For each question, check Yes or No.
If you check Yes for any question, provide full details on a separate sheet.
1.

Has your license to practice in any jurisdiction ever been or ever attempted to have
been denied, restricted, limited, suspended, revoked, or canceled?

2.

Has your license ever been subjected to probation either voluntarily or involuntarily?

3.

Has your license ever been withdrawn either voluntarily or involuntarily?

4.

Has any disciplinary actions or investigations been initiated against you by any state
licensure board?

5.

Have you been reprimanded and/or fined, by any local, state, or federal agency that
licenses providers?

6.

Have you ever been the subject of an informal or formal hearing process at any
healthcare organization?

7.

Have you been the subject of a complaint or have you been notified in writing that you
have been investigated as the possible subject of a criminal or civil action by any state
or federal agency that licenses providers?

8.

Have you ever been notified in writing that you are being investigated as the possible
subject of a criminal or disciplinary action by any health care organization (e.g., hospital,
HMO, PPO, IPA), professional group or society, licensing board, certification board,
PSRO or PRO?

9.

Have you been cautioned, reprimanded, or disciplined by any institution, any local,
state, or national professional society or regulatory agency?

10. Has your employment and or clinical privileges at any hospital, clinic, or other health
care setting ever been denied, suspended, revoked, reduced, restricted, not renewed,
voluntarily or involuntarily relinquished, denied renewal, or has probation ever been
invoked?

TN 2008-19
(11/19/2008)

Yes

No

Manual Exhibit 3-1-A
Page 10 of 20
IMPORTANT: All parts of this application must be completed. No part of this application may be
completed by writing “See CV.”
PROFESSIONAL PRACTICE QUESTIONS (Continued)
11. Have you ever voluntarily or involuntarily withdrawn your application for clinical
privileges or terminated clinical privileges before a hospital or health facility’s governing
board made a decision?
12. Have you ever been reprimanded, censured, excluded, suspended, and/or disqualified
from participating in or voluntarily withdrawn, to avoid an investigation by Medicare,
Medicaid, Tri-Care, and/or any other governmental health related programs?
13. Have Medicare, Medicaid, Tri-Care, PRO authorities, and/or any other third party payers
brought charges against you for alleged inappropriate fees, and/or quality of care
issues?
14. Has any information pertaining to you, including malpractice judgments and/or
disciplinary action ever been reported to the National Practitioner Data Bank or any
other practitioner data bank?
15. Has your federal DEA number and/or state controlled substance license been
suspended, revoked, restricted, limited, or relinquished either voluntarily or
involuntarily?
16.

Have you been notified in writing that you are being investigated as the possible subject
of a criminal or disciplinary action with respect to your DEA or controlled substance
registration?

17. Have you had a claim for professional negligence asserted against you in the past 10
years? (If yes, you are required to note the final judgment and settlements involving
yourself as a practitioner. Include date, amount of settlement.)
18. Have liability claims, judgments or settlements been made against a hospital,
corporation, or the United States Government in professional liability suits based on a
case with which you were professionally associated? (If yes, you are required to note
the final judgment and settlements involving yourself as a practitioner.)
19. Have you ever withdrawn from or been suspended, dismissed, or expelled from a
professional school or postgraduate training program, or has any third party ever
attempted to have you withdrawn, suspended, dismissed, or expelled from a
professional school or postgraduate training program?
20. Have you ever been placed on probation or taken a leave of absence from a medical,
dental, or other graduate school or postgraduate training program?
21. Have you been charged with or convicted of a crime (other than a minor traffic offense)
in any state or country?
22. Have you been the subject of a civil or criminal complaint or administrative action, or are
you being investigated as the possible subject of a civil, criminal, or administrative
action regarding sexual misconduct, child abuse, domestic violence, or elder abuse?
23. Do you have, or has it been suggested to you that you have, a history including the
present, of any physical, mental, or emotional impairment that either you or an objective
third party might think would limit your ability to meet the duties associated with clinical
staff membership and which could require an accommodation for you to exercise your
clinical privileges and clinical staff duties completely and safely? (If yes, please describe
the accommodation needed.)
24. Do you have, or has it been suggested to you that you have, a diagnosed or
undiagnosed chemical dependency (i.e., alcohol, illegal drugs, prescriptive drugs, etc)?

TN 2008-19
(11/19/2008)

Yes

No

Manual Exhibit 3-1-A
Page 11 of 20
IMPORTANT: All parts of this application must be completed. No part of this application may be
completed by writing “See CV.”
PROFESSIONAL PRACTICE QUESTIONS (Continued)
25. Are you currently engaged in illegal use of any legal or illegal substances?
26. Are you currently participating in a supervised rehabilitation program and/or
professional assistance program, which monitor you for alcohol and/or substance
abuse?

TN 2008-19
(11/19/2008)

Yes

No

Manual Exhibit 3-1-A
Page 12 of 20

CERTIFICATION
By signing this application, I certify that all the information submitted by me in this
application is true and complete to the best of my knowledge. I agree to immediately
disclose to the governing body if any answer to a question above becomes “Yes” while
staff membership and/or privileges are pending or have been granted.
I agree to abide by all lawful standards, policies, rules, regulations, and bylaws of the
facility, the Area, the Indian Health Service, the U.S. Public Health Service, and the
Department of Health and Human Services, as they apply to my responsibilities and
practice as a member of the clinical staff.
I further agree to answer any questions concerning the contents of this application
either during the application process or subsequent to having been granted privileges.
I agree that inquiries may be made to any federal or private sector facility with which
I have been affiliated.
I pledge to maintain an ethical practice and to provide for the continuous care of all my
patients.

Applicant’s Signature

TN 2008-19
(11/19/2008)

Date

Manual Exhibit 3-1-A
Page 13 of 20

Indian Health Service
Health Screens/Immunizations
1. Rubella and Measles Immunity
Applicants requesting hospital/clinic privileges are required to submit evidence of
rubella and measles immunity prior to being granted privileges. Individuals born
before 1957 do not need to submit proof of immunity to measles. If the titer is
negative, the applicant must receive the rubella and measles vaccine. Please
submit documentation that your rubella and measles immunity was positive or that
that you have received the vaccine.
2. TB Skin Test
Applicants requesting hospital/clinic privileges are required to submit documentation
of a current (within the past 12 months) TB skin test or chest x-ray if the skin test
was previously positive.
3. Hepatitis B Immunity
Health care professionals are at risk of acquiring Hepatitis B virus (HBV) infection
due to occupational exposure to blood and other potentially infectious materials.
The Indian Health Service strongly encourages applicant to obtain the Hepatitis B
vaccination series. However, this is not required as a condition of employment.
I have received the Hepatitis B vaccine.
My Hepatitis B antibody test results indicate prior exposure.
I decline the Hepatitis B vaccine at this time.
I have been given the opportunity to be vaccinated with Hepatitis B vaccine at
no charge to myself; however, I decline the Hepatitis B vaccine at this time.
I understand that by declining this vaccine, I continue to be at risk of acquiring
Hepatitis B virus (HBV) infection, a serious disease, due to my occupational
exposure to blood or other potentially infectious materials. If in the future I
continue to have occupational exposure to blood or other potentially infectious
materials and I want to be vaccinated with the Hepatitis B vaccine, I can
receive the vaccination series at the service unit where I am employed or
contracted at no charge to me.

Applicant’s Signature

TN 2008-19
(11/19/2008)

Date

Manual Exhibit 3-1-A
Page 14 of 20

Indian Health Service
Statement of Understanding and Release
I authorize the Indian Health Service (IHS) and its representatives to inquire of any
individual or entity with whom or which I have been associated (including medical
malpractice carriers) who or which it deems relevant in its assessment of my
professional competence, character and ethical qualifications. This includes any
information otherwise protected from disclosure by the Privacy Act, 5 United States
Code (U.S.C.) 552a, et seq. and/or the Health Insurance Portability and Accountability
Act of 1996, Public Law 104-191. This authorization includes copying and inspecting
any documentation (including but not limited to any general medical records, behavioral
health records and substance abuse treatment records), which the IHS and its
representatives deem relevant.
I consent to the disclosure by the IHS and its representatives of any information
regarding my professional services at any IHS facility to any individual or entity to whom
or which I subsequently apply for clinical privileges, membership, or licensure.
Additionally, I release the IHS from any liability for providing such information in
response to any inquiry made by any IHS employee to another IHS employee.
I release from any sort of liability the United States, the IHS, any of their
representatives, and any third parties from whom or which is obtained either information
or documentation for the above purposes.
I understand that I have the right to review information received about me from any
outside primary source except references or recommendations that are peer review
protected. In the event that the information obtained from outside primary sources
varies substantially from the information I have provided, I am aware that I have the
right to review and correct, if necessary, the information obtained.
Upon request, I agree to appear for purposes of responding to questions relating to any
record, document or information obtained pursuant to the foregoing paragraph. I
understand that my refusal to so appear may constitute cause for future denial of clinical
privileges and/or appointment to any medical staff or other healthcare position for the
IHS.
All information submitted by me in this application is true and correct to the best of my
knowledge. I understand that any intentional misstatement in or omission from this
application may constitute cause for denial of appointment or summary dismissal from
the clinical staff, at the sole discretion of the deciding entity. I agree that in either of
these events, I waive all rights of recourse and damages against the United States, the
IHS, and its representatives.

Applicant’s Signature

TN 2008-19
(11/19/2008)

Date

Manual Exhibit 3-1-A
Page 15 of 20

Indian Health Service
Statement of Health
By my signature hereto, I represent that presently, and for five years prior to the date of
my signature, I do not have, have not had, and have not been diagnosed and/or treated
as having any illness, condition or symptom relating to any physical or behavioral health
condition that would impact in any manner upon my ability to either practice medicine in
general, or perform any of the functions in particular that are set out in the position
description of the position for which I am presently applying.
OR
I have an impairment that
affects my ability to perform the clinical privileges requested and for which
I require special accommodation (describe the accommodation needed).
does not affect my ability to perform the clinical privileges requested.
No special accommodations are needed.

Applicant’s Signature

Date

This statement must be confirmed by either the director of your training program,
chief of staff, or personal primary physician, as required by accrediting bodies.
I hereby confirm that the provider identified above
does
does not currently
have any health problems (including disability, emotional stability, drug, or alcohol
dependency) that might impair his/her ability to care for patients.
Reasonable accommodation needed: ________________________________

Name (printed or typed)

Signature

Title

Date

Address

Daytime Phone No.

TN 2008-19
(11/19/2008)

Manual Exhibit 3-1-A
Page 16 of 20

Indian Health Service
Certification of Professional Licenses and Certificates
I certify that my professional licenses and certifications (nurse, medical, dental, or other
health profession) have not been terminated, suspended, or revoked in any state, the
District of Columbia, or Puerto Rico.
I currently hold active licenses and certifications in the following states and
organizations:
State/Organization

License/Certificate Number

Expiration Date

I have inactive licenses and certifications in the following states and organizations:
State/Organization

License/Certificate Number

Expiration Date

I also certify, as required by the false statements provisions of the Program Fraud Civil
Remedies Act of 1986, 45 Code of Federal Regulations (CFR) 79, that to the best of my
knowledge, each of the above statements are true, accurate, and do not omit any
material or facts which would render the statement false, fictitious, or fraudulent as a
result of omission.

Applicant’s Signature

Name (printed or typed):
Address:
City, State, Zip Code:
Phone:

TN 2008-19
(11/19/2008)

Date

Manual Exhibit 3-1-A
Page 17 of 20

Indian Health Service

Confidential Malpractice Claims Information Report
APPLICANT: Complete this form if you answered “Yes” to either professional
liability question (Question 17 or 18) on Page 10.
Note: If you have more than one incident to report, complete a separate Supplemental Confidential Malpractice Claims
Information Report for each incident. Print and sign each additional report and mail with your completed application.

Please furnish the following information regarding any lawsuits or complaints against
you. It is your responsibility to provide external verification (i.e., statement from an
attorney, court records, etc) of your response if requested. You may choose to have
your attorney complete this form.
Date of Incident:

1. Date of Claim:
2. Where incident occurred:
3. Claimant/patient name:

4. Nature of incident (type of case, procedure, major allegation, other pertinent
information:

5. Current status:

Pending/Open or

Closed

(date)

If closed, indicate:
Dropped

Dismissed

Appeal:
Judgment for plaintiff: $

TN 2008-19
(11/19/2008)

Judgment for defendant (you)
Settled: $

Manual Exhibit 3-1-A
Page 18 of 20

Represented by Legal Counsel for this claim/malpractice lawsuit?

Yes

If yes, give name and address of counsel:

6. Name of insurance company that provides/provided coverage for this claim:
Name of Insurance Company:

Policy Number:

Address:

City:

Phone:

Fax:

State:

7. Additional comments:

Signature:

Date:

Printed
Name:
Report
number:

TN 2008-19
(11/19/2008)

of

report(s)

Zip:

No

Manual Exhibit 3-1-A
Page 19 of 20

Indian Health Service
Privacy Act Notice for Credentials and Privileges Review
Process for the Medical Staff
The Privacy Act of 1974, 5 United States Code (U.S.C.) 552a, requires that a Federal
agency provide a notice to each individual from whom it collects information.
1. The authority for collecting the information requested is found in Indian Self
Determination and Education Assistance Act (25 U.S.C. 450); Snyder Act (25
U.S.C. 13); Indian Health Care Improvement Act (25 U.S.C. 1601 et. seq.); and the
Transfer Act (42 U.S.C. 2001-2004).
2. The principal purpose for collecting the information requested is to systematically
review the credentials of all current members of Indian Health Service (IHS) medical
staff and those of persons applying for positions on IHS medical staff, either as
employees or contractors, regarding membership and the granting of clinical
privileges.
This information is being requested to ensure that members of the IHS medical staff
are qualified, competent, and capable of delivering quality health services
consistent with those of the medical community at large and that they are granted
privileges commensurate with their training and competence and with the ability of
the facility to provide adequate support equipment, services, and staff. This
responsibility includes the initial review and verification of a provider’s credentials
for the purpose of determining eligibility for medical staff membership. The
applicant’s training, prior experience, and current competence, the needs of the IHS
medical staff relative to patient load and diagnostic caseload mix, and the ability of
the facility to provide adequate support facilities, services and staff must be
considered prior to granting medical staff membership an delineating specific
medical staff privileges. This responsibility requires a mechanism whereby the
credentials and clinical privileges will be evaluated, re-evaluated, and recertified on
a recurring and standardized basis.
3. Information contained in the records created for these purposes will be maintained
by IHS staff in a confidential manner. Releases of this information will only be made
on a “need to know” basis to employees of the Department of Health and Human
Services (HHS) in the performance for the following routine uses: Records in part or
total, may be disclosed to:
a) Authorized organization to conduct program evaluations studies sponsored by
IHS (e.g., Joint Commission).

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b) State or local government health profession licensing boards, to the National
Practitioner Date Bank (NPDB) established under title IV of Public Law (P.L.) 99660, to the Federation of State Medical Boards and/or to similar entities to inform
them of current or former IHS medical staff members whose professional health
care activity so significantly failed to conform to generally accepted standards of
professional medical practice as to raise reasonable concern for the health and
safety of members of the general public. This will be done within the guidelines
for notice, hearing and appellate review as delineated in the medical staff bylaws
for the IHS facility and/or within other HHS or IHS regulations or policies.
c) References listed on the IHS medical staff application for the purpose of
evaluating your professional qualifications, experience, and suitability.
d) State or local health professional licensing boards, health professional
organizations, the NPDB established under Title IV of P.L. 99-660, the
Federation of State Medical Boards or similar entities for the purpose of verifying
that all claimed background and employment data are valid and all claimed
credentials are current and in good standing.
e) Other agencies of the Federal Government, State, and local governments and
organizations in the private sector you have or will apply to for clinical privileges,
membership, or licensure for the purpose of documenting your qualifications and
competency to provide health services in your health profession based on your
professional performance while employed by the IHS.
f) Department of Justice in case of litigation.
g) Federal, State or local agency charged with enforcing or implementing a statute,
rule, regulation or order when information contained in the record indicates a
violation or potential violation of law, whether civil, criminal, or regulatory in
nature.
h) Indian Health Service Staff will maintain a log of such disclosures. You may
review a copy of this log of disclosures. You may review a copy of this log of
disclosures or review copies of materials contained in your medical staff
credentials and privileges file. To do so, contact the Clinical Director of your
facility or the Area Director, if the official file is maintained at the Area Office.
i) Information collected through the use of IHS Credentials and Privileges forms are
contained in System of Records: 09-17-0003 IHS Medical Staff Credentials and
Privileges Records, HHS/IHS/OHS.
j) Applicants are advised that failure to provide the information requested, including
Social Security Number, will result in a denial to receive, or to continue, funding
as an IHS medical staff member (direct or contract).

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