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ASM Test - Pre-Application
Introduction
Form Approved
OMB No. XXXX-XXXX
Exp. Date XX/XX/XXXX
Welcome to Indian Health Service
The Federal Health Program for American Indians/Alaska Natives
Our Mission: The overall mission of the Indian Health Service is to raise the physical, mental, and social and
spiritual health of American Indians and Alaska Natives (AI/AN) to the highest level.
Our Goal: To ensure that comprehensive, culturally acceptable personal and public health services are
available and accessible to American Indians & Alaska Native people.
Information and Tips for Completing the Pre-Application
The pre-application is used to identify individuals who meet the minimum qualifications to receive
a full application for medical staff membership and/or privileges. Once the pre-application is
reviewed, the applicant will be notified if the minimum qualifications are met to receive a full
application.
INSTRUCTIONS: Enter all pertinent information, as applicable. Fill out all required sections and
fields that are marked in Red; these are mandatory and must be completed to submit the
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application. At any point, the application may be saved by clicking Save and completed at a
later time. The blue toolbar at the top right provides additional help. The definition of
"applicant" within this application is the individual requesting medical staff membership
and/or clinical privileges.
Packet Documents included on the previous home screen are MANDATORY. These must
be viewed and/or filled out and uploaded into the Files section on this application.
Please note that any documents that require electronic signature are found at the end
of the application.
The Head Icon at the top right allows the applicant to change or reset the password and
authorize account access to a delegate.
Help Icon provides support if technical difficulties are encountered.
Return To Application after submitting the application, where the completed application
and supporting documents may be viewed, downloaded, or printed.
UPLOADING DOCUMENTS: Completed documents and forms must be uploaded in the Files
section of this application. Please contact the Medical Staff Credentialing Coordinator for
other delivery methods if technical difficulties are encountered.
LENGTHY RESPONSES: Each text field in this application has a limit of two lines. If a response
exceeds two lines of text, please upload the response as a Word or PDF document in the Files
section of this application.
ATTENTION: Misrepresentations, inaccuracies, or falsification of any information may be
grounds for denial or termination of medical staff appointment and/or associated clinical
privileges, and may be subject to the reporting requirements of the National Practitioner Data
Bank (NPDB), and state and federal licensing boards.
INCOMPLETE APPLICATIONS & MISSING DOCUMENTS: Applications with incomplete
information or missing documents will be returned to the applicant and delay the processing
of the application.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0917-0009. The time required to complete this
information collection is estimated to average 45 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, to review and
complete the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: Indian Health Services,
OMS/DRPC, 5600 Fishers Lane, 09E70, Rockville, MD 20857, Attention: Information Collections
Clearance Officer.
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Personal Information
Enter the requested information.
Mandatory fields are in Red. Click Edit to modify this section and Save to save the information entered.
First Name
Middle Name
Last Name
Test
Degree
Degree 2
Degree 3
E-Mail
Cell
Citizenship
Birth Date
MM/DD/YYYY
SSN
-NPI
Save
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Cancel
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Addresses 0 of 1 Required
List home and office addresses.
Mandatory fields are in Red. Additional addresses may be added by clicking the Add button. Click Save when
finished.
Delete
New Address*
Type
Address1
Address 2
City
State
Postal Code
County
Country
Telephone
Fax
Email
Save
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New Addresses
+ Add
Alias/Other Names Used
List ALL aliases or other names ever used.
Additional aliases may be added by clicking the Add button. Click Save when finished.
Delete
New Alias*
First Name
Middle Name
Last Name
Save
New Alias/Other Names Used
Cancel
+ Add
Education/Training
List all institutions and colleges where education and training was received. This includes all
undergraduate education, graduate education, residencies, and fellowships. Also list all colleges where
a degree was transferred from or not obtained. If the exact start or end date is unknown, please ensure
that the month and year are correct. State in the Comments field if you completed the
education/training. If you did not, please explain why.
If applicable, ECFMG information MUST be entered in this section.
If a residency or fellowship was completed, please indicate the specialty and program name in the
Subject field. If internship information is submitted, please add if the internship was rotating, mixed, or
straight in the Subject box. If a straight residency was complete, please also include the discipline.
Mandatory fields are in Red. Education may be added by clicking the Add button. Select the appropriate
Education Type, then search the name or city in the Search box. Click Save when finished.
New Education*
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Education Type
Search
Enter Name or City to search
Name
Address
Address 2
City
State
Postal Code
Country
Start Date
MM/DD/YYYY
End Date
MM/DD/YYYY
Degree Earned
Subject
Comments
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Save
New Education/Training
Cancel
+ Add
Licenses/Credentials
All the following credentials listed below are required (please note that other credentials may be
required by the facility in which you are applying):
1. ALL inactive and active professional state licenses
2. ALL inactive and active DEA, CDS, or other licenses or registrations
3. Current life support certifications (Example: BLS, ACLS, ATLS, NRP, PALS, ALSO, etc.)
Please document any limitations or restrictions in the Status section.
The License Number and State fields are required to submit the application. If a license or credential
does not have a license number associated with it, please add N/A in the License Number field. If a
license or credential does not have a state associated with it, add a state that you are licensed in or
reside in. Please include any additional information in the Comments field.
Mandatory fields are in Red. Begin by clicking Add, then selecting the Type. Click Save when finished.
New Credential*
Delete
Type
License Number
State
Expiration Date
MM/DD/YYYY
Status
Comments
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Save
New Licenses/Credentials
Cancel
+ Add
Board Certifications
List all board certifications currently and previously held. (Note that state licenses granted by state
licensing boards should be added in the Licenses/Credentials section.)
If not certified, please provide an explanation in the Comments section. Also document if an application
was submitted for board certification and the examination date, if applicable.
Mandatory fields are in Red. List your primary board certification first. Begin by clicking the ADD button,
and type the board acronym and/or name in the Search box. Once selected, it will pre-populate fields.
New Board Certification*
Delete
Search
Enter Name or City to search
Name
Address
Address 2
City
State
Postal Code
Country
Specialty
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Certified In
Certificate Number
Certification Status
Initial Certification
MM/DD/YYYY
Expiration Date
MM/DD/YYYY
Comments
Save
Cancel
New Board Certifications
+ Add
Files
Upload the following required documents. Forms that require signature are either housed on the login
screen, at the end of the application for electronic signature, or will be emailed to you.
1. Current curriculum vitae or resume
2. Completed Statement of Understanding & Release Form (MUST be uploaded to submit
application.)
To upload a digital document (pdf, jpg, etc):
1. Select Add
2. Select a File Type
3. Enter a Description (Optional)
4. Click on Click To Upload to browse for the file
5. Click Save to complete the upload
If unable to perform a document upload, please contact MD-App Support at 1-800-736-7276 or the
Medical Staff Office.
New File*
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File Type
File Description
Upload File
Click to Upload
Save
Cancel
New Files
+ Add
Attestation Questions
Please answer **ALL** attestation questions. For any "Yes" answers, please provide further
explanation in the space provided.
Yes
No
Have any licenses (state license, DEA, and/or state controlled
substance license) in any jurisdiction ever been or ever attempted
to have been denied, restricted, limited, suspended, revoked,
canceled, reprimanded, or censured, and/or have you ever
practiced without a license?
Yes
No
Have you ever been cautioned, reprimanded, fined, disciplined,
investigated, excluded, subject of a complaint, or notified of any
criminal, civil, or disciplinary action by local, state, or federal
licensing board (state, DEA, CDS, etc.), certification board,
professional organization/agency, accrediting or professional
standards review organization, or governmental health related
program (Medicare, Medicaid, TriCare, etc)?
Yes
No
Have you ever been the subject of an informal or formal hearing
process at any healthcare organization?
Yes
No
Has your employment, medical staff membership, 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?
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Yes
No
Has any information pertaining to you, including malpractice
judgements and/or disciplinary action, ever been reported to the
National Practitioner Data Bank or any other practitioner data
bank, or any other federal or state board oversight authority?
Yes
No
Have any professional liability claims, judgements or settlements
ever been made against you, a healthcare organization, or the
United States Government, based on a case with which you were
professionally associated? If yes, please explain. Include the final
judgement and settlements.
Yes
No
Have you ever had professional liability coverage denied, refused,
or canceled by a professional liability insurance company?
Yes
No
Have you ever been placed on probation or taken a leave of
absence from medical, dental, or other graduate school or
postgraduate training program?
Yes
No
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, elder abuse, or any
other violent crimes?
Yes
No
Do you have, or has it ever been suggested to you that you have, a
diagnosed or undiagnosed chemical dependency (i.e. alcohol,
illegal drugs, prescriptive drugs, etc), are engaged in illegal use of
any legal or illegal substances, or are currently participating in a
supervised rehabilitation program and/or professional assistance
program, which monitor for alcohol and/or substance abuse?
Yes
No
Has it been more than 12 months since you have provided patient
care in a professional setting?
Yes
No
Have you been charged with or convicted of a crime, other than a
minor traffic offense, in any state or country?
Submit Application
Final Steps:
1. Read the Applicant’s Certification Statement:
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 or staff membership and/or
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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.
2. Click Submit Application. (Once the application has been submitted, you may go back to edit your
data by clicking Unsubmit on the main login page. You may also print the application by clicking
View Application.)
3. On the Electronic Signature page enter your complete and legal name, check the box indicating
that you have read and agree to be bound by the Applicant’s Certification Statement, and that to
the best of your knowledge, all information provided on the application is true and accurate, and
that no material or facts which would render the statement false, fictitious, or fraudulent is
omitted.
The application is incomplete
Submit Application
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| File Type | application/pdf |
| File Modified | 2023-04-13 |
| File Created | 2023-04-13 |