0917-0009 Affiliation Verification

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

Date

«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 Has the applicant’s medical staff membership or status at your hospital ever been revoked, not renewed, or subject to probationary conditions, or have proceedings begun that could result in any such action?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 current illegal use of drugs, quality of care problems, or other issues 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: _______________

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. (3), CMS CoP §482.12(a)(6) and §482.22(c)(4) and [the nature and extent of confidentiality to be provided, if any (the Privacy Act, 5 U.S.C. § 552; the Privacy Rule promulgated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Part 160 and Subparts A and E of Part 164; the Indian Health Care Improvement Act, 25 U.S.C. § 1675; and the Confidentiality of Substance Use Disorder Patient Records regulations, 42 C.F.R. Part 2)]. 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.