Form 0917-0009 Affiliation Verification

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service Indian Health Service VERIFICATION OF AFFILIATION «FacilityName» Address

August 2, 2023

«RS_Name»

«RS_Address»

«RS_City», «RS_State» «RS_Zip» Fax Number: «RS_Fax»

Re: «FormalNameWithDegree»

The practitioner listed above has applied for appointment/reappointment at «FacilityName» Indian Medical Center. Please verify the information requested below. «Hisher» consent for release of information is attached «Image:File_REL». Please return via secure email or fax to Attn: «UserFullName», «UserFax». Thank you.

«UserFullName»

Medical Staff Professional

URGENT

Dates of Staff Membership: From _________________ To __________ Observed? ____ Unobserved?____

Staff Category: ___________________Approximate number of patient contacts in the past year: _________

1. Has applicant’s clinical privileges ever been denied, revoked, restricted, or granted with limitations?	YES*___ NO___
2. Did «heshe» attempt procedures beyond his/her skills or training?	YES*___ NO___
3. Has the applicant’s medical staff membership or status at your hospital ever been revoked, not renewed, or subject to probationary conditions, or have proceedings begun that could result in any such action?	YES*___ NO___
4. Are you aware of any malpractice litigation or claims involving the applicant?	YES*___ NO___
5. Do you know of any behavioral, health, substance abuse, or quality of care problems for which the applicant was disciplined or counseled while on staff at your facility?	YES*___ NO___
6. Would you recommend «himher» for appointment to our medical staff?	YES___ NO*___
7. Do you find this provider to be ethical and of high moral character?	YES___ NO*___
8. Evaluation completed: _____ Based on close observation and/or personal knowledge. _____ Based on review of Credentials file.	(*Provide explanation)

Comments: ___________________________________________________________________________________

Signature: ___________________________________ Title: __________________________________

Printed Name: ____________________________Phone: ________________Date: _______________