Medical Staff and Allied Health Staff

Code of Excellence and Code of Conduct

Acknowledgement Form

This is to certify that I have received, read and understand the Code of Excellence and Code of Conduct.

The Code of Excellence/Code of Conduct is available to me at www.andersonhospital.org – under the Patients and Visitors tab – Legal and Regulatory Information, and on the Intranet - Home tab.

I acknowledge that I am fully aware that compliance with the Code of Excellence and Code of Conduct is a condition of my continued medical staff/allied health staff membership with Anderson Healthcare.

I further pledge and acknowledge the following:

1. That it is my duty to know and understand the ethical standards, legal standards and company policies applicable to performing my duties.

2. I pledge to act in compliance with the Code of Excellence and Code of Conduct and any compliance policies applicable to my responsibilities.

3. I pledge to be in full compliance with all applicable laws, federal health care program requirements and with Anderson policies and procedures.

4. I will report any conduct that I believe constitutes a violation of the Code of Excellence or Code of Conduct as outlined in the Codes.

5. I will seek advice from the Compliance Officer concerning appropriate actions that I may need to take in order to comply with the Code of Excellence or the Code of Conduct.

6. I understand that failure to comply with the Code of Excellence or Code of Conduct may subject me to disciplinary action.

__________________________________________________________________ Signature

__________________________________________________________________

Printed Name

__________________________________________________________________ Date

6800 State Route 162 Maryville, IL 62062

Phone: 618-391-6141 Fax: 618-288-2164

Provider Contact Information Please provide your contact numbers below, in order of preference, for the floors to contact you.

NAME:

CONTACT NUMBER

IN ORDER OF PREFERENCE

TYPE OF NUMBER

SPECIAL INSTRUCTIONS

1.

CELL HOME

PAGER OFFICE

EXCHANGE

2.

CELL HOME

PAGER OFFICE

EXCHANGE

3.

CELL HOME

PAGER OFFICE

EXCHANGE

4.

CELL HOME

PAGER OFFICE

EXCHANGE

5.

CELL HOME

PAGER OFFICE

EXCHANGE

Contact Number for E-prescribing clarification

CELL HOME

PAGER OFFICE

EXCHANGE

PRIMARY OFFICE ADDRESS: (PLEASE NOTE: THIS IS THE ADDRESS MEDICAL RECORD REPORTS WILL BE MAILED TO, IF APPLICABLE) OFFICE#: FAX #: EMAIL ADDRESS:

Provider Signature: ___________________________________ Date: __________________

Page 1 of 1

Supplemental Information

Name: 1. Home Address:

2. Phone Number: Home Cell

3. Marital Status (optional)

4. Name of Significant Other (optional) 5. Emergency Contact (if different from above)

6. Has your professional liability insurance carrier and/or the amount of professional liability insurance carrier changed? Yes No If yes, explain

7. Has your medical staff membership, staff category, scope of clinical privileges, or employment been

voluntarily or involuntarily changed or terminated at any hospital or other institution since your last application?

Yes No If yes, explain

8. Name(s) of physician(s) who have privileges at Anderson Hospital, with the same specialty as yours, who

will provide coverage. REQUIRED PER THE MEDICAL STAFF BYLAWS - 1.3(b)

8. Peer Evaluations are required by the Joint Commission. Please provide name and address of peer, within

your same specialty and preferably on staff at Anderson Hospital, whom we can contact to complete your Peer Evaluation, if necessary.

MEDICAL STAFF MEMBER CONSENT AND RELEASE

I extend absolute immunity to, and release from any and all liability, Anderson Hospital, its Medical Staff, its Authorized Representatives, and any Third Parties, all as defined below, for any acts, communications, statements, recommendations or disclosures performed in good faith and without malice, including otherwise privileged or confidential information, relating to or in connection with this Reapplication or the consideration of the privileges sought herein. I specifically authorize Anderson Hospital and its Authorized Representatives to consult with any Third Party who may have information, including otherwise privileged or confidential information, bearing on my professional qualifications, credentials, clinical competence, character, mental or emotional stability, physical condition, ethics, behavior or other matter bearing on my satisfaction of the criteria for initial and continued appointment to the Medical Staff, and to inspect or obtain copies of any and all communications, reports, records, statements or documents from Third Parties relating to such matters. I also specifically authorize said Third Parties to disclose and release any such information to Anderson Hospital and its Authorized Representatives upon request. Any and all information received from Third Parties shall be confidential and shall not be released to the Applicant. I further authorize and consent to the release of information and records concerning me by Anderson Hospital to other hospitals, medical associations, governmental agencies or other bodies concerned with professional competency, medical malpractice or practitioner licensing, and I hereby release from liability Anderson Hospital and its Authorized Representatives for so doing. The Term “ Authorize Representatives” means Anderson Hospital and any of the following individuals who have any responsibility of obtaining or evaluating my credentials, or acting upon my Reapplication or conduct in Anderson Hospital: The members of Anderson Hospital’s Board of Trustees and their appointed representatives; the members and officers of the Medical Staff of Anderson Hospital; the President of Anderson Hospital or his designees; other hospital employees; consultants to the hospital and the hospital’s attorneys. The term “ Third Parties” means all individuals and entities, including but not limited to physicians, health practitioners, hospitals, government agencies, associations, partnerships and corporations, from whom information concerning me or this Reapplication has been or is requested by Anderson Hospital or its Authorized Representatives, or who have requested such information form Anderson Hospital or its Authorized Representatives.

_____________________ ____________________________________________ Date Signature

____________________________________________ Printed Name

REAPPLICANT'S ATTESTATION I hereby apply for medical staff reappointment and clinical privileges as requested in this reapplication. I am willing to make myself available for interviews in regard to this reapplication. As a reapplicant, I have the burden of producing adequate information for proper evaluation of this Reapplication. I agree to provide Anderson Hospital with updated current information regarding all questions on this reapplication as such information becomes available and such additional information as may be requested by Anderson Hospital or its Authorized Representatives. I represent that the information given in or attached to this reapplication is accurate and fairly represents that current level of my training, experience, capability and competence to practice. I REALIZE AND AGREE THAT ANY MISREPRESENTATION, SIGNIFICANT MISSTATEMENT OR OMISSION IN THIS REAPPLICATION SHALL CONSTITUTE GROUNDS FOR DENIAL OF REAPPOINTMENT OR TERMINATION OF ANY CLINICAL PRIVILEGES GRANTED. I understand that this reapplication will be considered in accordance with the By-laws, Rules and Regulations of the Medical Staff of Anderson Hospital, and agree to be bound by those By-laws, Rules and Regulations. I understand that I have the burden of establishing my eligibility and competence. By applying for reappointment and clinical privileges, I accept that I have the responsibility to keep this reapplication current by informing the hospital, through the Chief Executive Officer or his designee. I understand I am obligated to notify the hospital, through the Chief Executive Officer or his designee, immediately for professional license revocation, federal Drug Enforcement Agency license revocation, or any lapse in professional liability coverage. I further understand I must notify the hospital, as noted above, within in 5 days of any corrections, updates, and modifications for Medicare or Medicaid sanctions, revocation of any hospital privileges, or conviction of a felony, and within 45 days for any other change in information from the date the health care professional knew of the change. All updates should be made on the Healthcare Professional Data Gathering form, which is mandated by the state of Illinois. I specifically agree to abide by all By-laws, policies, directives, Rules and Regulations as are in force during the time I am reappointed to the Medical Staff or exercise clinical privileges at Anderson Hospital. I agree to abide by all of the ethical principles established by the national association of my profession. I agree not to receive from or pay to any other physician, either directly or indirectly, any part of any fee paid for professional services. I agree to provide continuous care and supervision for all of my patients at Anderson Hospital.

_____________________ ____________________________________________ Date Signature

____________________________________________ Printed Name

HEALTH STATEMENT

To be completed by the reapplicant: Do you have a physical or mental condition which could affect your ability to exercise the clinical privileges requested or would require an accommodation in order for you to exercise the privileges safely and competently?

Yes No

Reapplicant Name (Please print) Reapplicant's Signature Date Regardless of how the above question is answered, the reapplication will be processed in the usual manner. If you have answered this question affirmatively and are found to be professionally qualified for medical staff appointment and the clinical privileges requested, you will be given an opportunity to meet with an appropriate committee to determine what accommodations are necessary or feasible to allow you to practice safely. To be completed by your Primary Care Physician (PCP): I do hereby certify that physician listed above is in good physical and mental health to carry out the duties necessary in the performance of his/her profession. Any limitations or restrictions placed on this Healthcare professional are as follows: Comments: Attending Physician (please print) Date

Attending Physician Signature

CONTINUING MEDICAL EDUCATION (CME’s)

List the continuing education sessions and hours which you have completed in the last two years. Attach either a copy of certificates of attendance for each program attended or list as follows:

Name of Program/Topic

Sponsored by

Dates of Attendance Hours

Total Hours

If requested, I agree to submit proof of attendance and program content. Provider Signature Date

LOW VOLUME VERIFICATION Date: _____________

To whom it may concern,

I am in the reappointment process and have had low activity at Anderson Hospital. I am requesting verification of my clinical activity to fulfill my reappointment requirements. I authorize you to release this information to Anderson Hospital. Please return this form ASAP. The form may be mailed to Anderson Hospital, Medical Staff Office, 6800 State Route 162, Maryville IL 62062 or faxed to 618-288-2164. Thank you. ____________________________________ ______________________________________________ Requesting Provider’s Signature Requesting Provider’s Printed Name

Please note: This information is to be completed by your PRIMARY FACILITY, NOT BY PROVIDER. Current Staff Status: __________________________ Date of Initial Appointment: _____________________ 1. Please provide the following utilization at your facility for the past two years:

Number of Admissions: ____________________________ Number of Procedures: ____________________________ *Provide a list of each procedure & the number performed Number of Consultations: ____________________________

2. Please provide a copy of this provider’s current delineation form from your facility. 3. 4. This provider’s clinical performance for the privileges he/she has been granted has been:

Acceptable _______ Above Average _______ Unacceptable _______ Average _______ Below Average _______

_______________________________________________ _________________________ Signature of Dept. Chairperson or Designee Date Printed Name & Title: ____________________________________________________________ Hospital/Organization: ____________________________________________________________ Address/City/State/Zip: ____________________________________________________________

CONFLICT OF INTEREST AGREEMENT

I agree to avoid all actual and perceived conflicts of interest and shall abide by the Conflict of Interest –Medical Staff Policy of Anderson. I understand that a conflict of interest arises when there is a conflict between one’s personal stake in a matter and his/her fiduciary responsibility to Anderson caused by a financial interest, position, activity or other relationship with a third party. I understand it is not possible to list all types of conflicts of interests, but agree that the following general principles are areas to consider as potential conflicts and agree to avoid them:

►Products and services are to be bought and sold based solely on their value and merit. If I am involved in purchasing goods or pricing services I may not give, receive, offer or solicit any personal gifts or favors or any payment in the nature of a bribe or kickback that influences or might appear to influence purchase and pricing decisions. ►Any outside activity, such as a second job or a significant interest in another business, shall not involve any personal interest that could affect my independent judgment with my duties or discredit or embarrass Anderson. ►I or my immediate family may not have any personal interest in any sale or purchase of property by Anderson. ►I may not convey Anderson property or proprietary or confidential information or provide unpaid services to a member of the public or to an employee or agent unless approved in writing by a member of senior management/Chair of the Board of Trustees, as appropriate. ►I shall disclose all possible conflicts of interest when those interests may affect or be perceived as affecting a decision on a proposed Anderson transaction or arrangement.

I may not enter into any agreement or arrangement that calls for a commission, rebate, consultant or service fee, bribe, kickback should suspect from the surrounding circumstances or after a good faith inquiry, that the intent or probable results is to reward improperly, either directly or indirectly including:

►Any employee or official or other representative of any government or governmental agency or entity (including the military). ►Any officer, director, trustee, employee, shareholder or other representative of an institution with which Anderson has an existing or prospective business relationship. ►Any officer, official, member or other representative of a union.

I will not give inducement to such individuals to take action favorable to Anderson or myself. The concept of an improper reward includes the giving of anything of value. Examples such as free or special price services or trips at Anderson’s expense, without a proper business purpose, may constitute an improper payment just as readily as a cash payment. No action that would otherwise be suspect shall be permissible merely because it appears to be customary in a particular location or particular area of business activity. I understand that the practices of write-offs, discounting and forgiveness of debt shall be subject to interpretation as gifts, inducements or even bribes. I understand that requests for special billing or payment procedures that suggest possible violations of law such as evasion of income tax, currency exchange controls or price, profit controls are contrary to policy and no such billing, or payment procedures shall be used. Such practices can also result in false, artificial or misleading entries in the books or records of Anderson and are prohibited. I understand that I am subject to termination of my position if it is determined that I have violated this agreement. ___________________________________________ ________________________ Signature Date ___________________________________________ Printed Name ___________________________________________ Medical Specialty Please list any actual or potential conflicts of interest that may be present as defined in this agreement. If there are no actual or potential conflicts of interest, enter: “None”. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

INSURANCE TO ALL MEDICAL STAFF MEMBERS: The Board Trustees on April 25, 1989, approved the Medical Staff By-Laws change concerning malpractice insurance and passed a Board resolution allowing for the following limits of malpractice insurance: A. Physicians granted privileges in the areas of Obstetrics and Gynecology, Anesthesia,

Orthopedic Surgery, Radiology, Pathology, Neurosurgery, General Family Practice including OB/GYN, and those retained to provide coverage in the Emergency Department will maintain a minimum of $1,000,000.00 per event or $3,000,000.00 on the aggregate.

B. Those physicians granted privileges in Internal Medicine, Cardiology, General Family

Practice excluding OB/GYN, General and Vascular Surgery, Ophthalmology, Gastroenterology, Otolaryngology, Dermatology, Urology, Pulmonary, Plastic Surgery, Rheumatology, Nephrology, Neurology, Chemotherapy, Psychiatry and Oral Surgery shall retain a minimum of $1,000,000.00 per occurrence and $1,000,000.00 in the aggregate.

C. Podiatrists (excluding orthopedic privileges) shall maintain a minimum of $200,000.00

per event or $600,000.00 in the aggregate. D. General Dentist (excluding oral surgeons) shall maintain $500,000.00 per occurrence and

$500,000.00 in the aggregate. E. All others who have privileges to admit patients to, or to treat patients in, Anderson

Hospital shall maintain $1,000,000.00 per occurrence and $1,000,000.00 in the aggregate. ***It is required that we retain proof of insurance and Anderson Hospital is to be named as the certificate holder.

TO: The Medical Staff of Anderson Hospital, Maryville, Illinois requires each Medical Staff appointee and applicant to provide evidence of medical professional liability insurance coverage in the exact amounts of coverage per occurrence and per annual aggregate. Please send a Certificate of Medical Liability Insurance or other documentation to Anderson Hospital verifying the class of my insurance, the exact limits of the coverage I have with your company, and claims history. I also authorize Anderson Hospital to verify specific privileges covered under my policy as well as any limitations of my coverage. If available, we have attached a copy of the policy for your convenience. Please identify Anderson Hospital as the certificate holder on my policy.

________________________________ _______________________ Signature Date ________________________________ Printed Name

Office Address City State Zip

Home Address City State Zip

NOTICE TO PROVIDERS

Medicare, Medicaid, and Champus payment to hospital is based in part on each patient’s principal and secondary diagnoses and the major procedure performed on the patient, as attested to by the patient’s attending physician by virtue of his or her signature in the medical record. Anyone who misrepresents, falsifies, or conceals this essential information required for payment of Federal funds, may be subject to fine, imprisonment, or civil penalty under applicable Federal laws.

I acknowledge that I have received and read the “NOTICE TO PROVIDERS” concerning Medicare, Medicaid and Champus payment to hospitals and the penalties as stated.

___________________________________ ______________________ Provider’s Signature Date ___________________________________ Printed Name