Emergency Preparedness

Appendix Q.1 Volunteer Management

Kern Medical Emergency / Disaster Temporary Privileges / Status Request Form

Please answer each of the following questions in full. If you answer yes to any of the questions, please provide a complete explanation on a separate sheet of paper.

1. Have any disciplinary actions been initiated or are any pending against you by any state licensure board? Yes No 2. Has your license to practice in any state ever been (voluntarily or involuntarily) denied, limited, suspended, revoked, reprimanded, relinquished, or is your license to practice in any state under current challenge? No 3. Have you ever been suspended, sanctioned or otherwise restricted from participating in any private, federal or state health insurance program (such as Medicare or Medical)? No 4. Has your narcotics registration certification ever been revoked (voluntarily or involuntarily), limited, suspended relinquished, or is it currently being challenged or reviewed? No 5. Has your employment, staff appointment, clinical privileges and/or scope of practice ever been (voluntarily or involuntarily) suspended, limited, revoked, not renewed, at any hospital or other healthcare facility? Yes Yes Yes

Yes

No

6. Are your staff appointment or clinical privileges or status and/or scope of practice at any hospital or other healthcare facility currently under investigation?

Yes

No

7. Has your current professional liability insurance carrier excluded any specific procedure from your coverage:

Yes

No

APPLICANT’S STATEMENT I certify that I am trained and experienced in the privilege /status requested, hold a current, unrestricted license to practice medicine in the state of California or another state and a current DEA certification (if applicable). Additionally, I certify that all information provided in this request form is true and accurate. I understand that in making this request, I am bound by the Kern Medical’s medical staff bylaws, rules and regulations, scopes of service and any and all policies and procedures in affect during this temporary status. I further understand that when the emergency / disaster no longer exists, these temporary privileges will be terminated and that I must request privileges/ employment or any other status through the normal staffing process, if I wish to continue any and all clinical services to the patients of Kern Medical. I will further surrender any and all materials and property of Kern Medical provided to me during this temporary timeframe.

Applicant’s signature: __________________________ Date: ______________

May 2008

Incident Command System Training

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