0917-0009 Pre Application MD App

2/1/24, 8:07 PM

Details - MD-App

Pre-Application

Introduction

Form Approved OMB No. XXXX-XXXX

Exp. Date XX/XX/XXXX

The Federal Health Program for American Indians/Alaska Natives

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.

To ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indians & Alaska Native people.

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.

Enter all pertinent information, as applicable. Fill out all required sections and fields that are marked in ; these are mandatory and must be completed to submit the

application. At any point, the application may be saved by clicking 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.

included on the previous home screen are . These must be viewed and/or filled out and uploaded into the section on this application.

Please note that any documents that require electronic signature are found at the end of the application.

at the top right allows the applicant to change or reset the password and authorize account access to a delegate.

provides support if technical difficulties are encountered.

after submitting the application, where the completed application and supporting documents may be viewed, downloaded, or printed.

Completed documents and forms must be uploaded in the section of this application. Please contact the Medical Staff Credentialing Coordinator for other delivery methods if technical difficulties are encountered.

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.

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.

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 [####-####]. This information collection is to be used in verifying an applicant’s credentials to meet agency policy, Centers for Medicare Conditions of Participation requirements, and accrediting body standards. The time required to complete this information collection is estimated to average less than 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is required to determine an applicant’s credentials to provide healthcare (IHS IHM 3-1.4 C. (1-2), CMS CoP §482.12(a)(6) and

§482.22(c)(4) and [the nature and extent of confidentiality to be provided, if any (5 U.S.C. 552a and 25 U.S.C. 1675)]. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Indian Health Service, 5600 Fishers Lane, mailstop: 09E07, Rockville, MD 20857, Attention: Information Collections Clearance Officer

United States Telephone Fax

E-Mail

Maiden

Address Address 2

Postal Code

End Date

l

Subject

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.)

Also document if an application was submitted for board certification and the examination date, if applicable.

Mandatory fields are in . List your primary board certification first. Begin by clicking the button, and type the board acronym and/or name in the box. Once selected, it will pre-populate fields.

Rehabilitation

Address Address 2 City

State

Postal Code Country

Rehabilitation

Certified In

Comments

Attestation Questions

Please answer **ALL** attestation questions. For any "Yes" answers, please provide further explanation in the space provided. Answering yes to questions will not necessarily disqualify an applicant.

false

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?

false

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.)?

false

Have you ever been the subject of an informal or formal hearing process (including hearing processes) by the federal government or any branch of the military, licensing board, hospital, healthcare organization, agency or professional association to revoke, suspend, restrict or limit a professional license/registration/permit?

false

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?

false

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?

false

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.

false

Have you ever had professional liability coverage denied, refused, or canceled by a professional liability insurance company?

false

Have you ever been placed on probation or taken a leave of absence from medical, dental, or other graduate school or postgraduate training program?

false

Have you ever been arrested, cited, charged with or convicted of a felony or misdemeanor other than minor traffic violations, regardless of the outcome? This includes withheld judgements and matters that have been expunged.

false

Are you currently engaged in illegal use of any legal or illegal substances?”

false

Has it been more than 12 months since you have provided patient care in a professional setting?

false

Do you have any reason to believe that you could pose a risk to the safety or well-being of patients?

https://mds.ihs.gov/mdapp/ihs//Application/Details/cf733549-878f-4afa-9b08-175281c4476e

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