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Martina Diditright, MD: CV
Martina Did itright, MD
1001 Garden Drive
Healthy Town, Good State, USA
Ph: 000-123-456 Fax: 111-222-333
Email: mdid [email protected]
Education and Postgraduate Training:
7/ 1996-6/ 1999 Post Grad uate Training
Goodville Hosp ital, Greene City, Good State, USA;
Goodville Hosp ital Family Practice Group, Greene City, Good State, USA.
7/ 1992-6/ 1996 University Medical College, Small State, USA
9/ 1988-5/ 1992 Urbanville College, Commonwealth of Urbanville, USA. BA (Chemistry)
Board Certification: 1999 Family Medicine, 2009 recertification Family Medicine
2008 Emergency Medicine
Other Certifications: ACLS current (expires 12/ 31/ 2013)
Licensure: Good State, USA (license no. 991122, expires 12/ 31/ 2014)
Commonwealth of Urbanville (licensure no. 007008, expires 08/ 31/ 2015)
DEA AB12340 expires 7/ 31/ 16
Practice Experience:
03/ 2012-07/ 2013 Urbanville Hospital Family Practice Group (Urbanville, USA)
01/ 2011-12/ 2011 Wellness Hospital --- emergency department (Urbanville, USA)
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07/ 2002-12/ 2010 Did itright Family Practice, Good State, USA.
07/ 1999-05/ 2002 Goodville Family Medical Center (Goodville, Good State)
Honors/Awards: Urbanville Volunteer Award (2011, 2012) (established annual free community
Health Fair)
Publications: ‘‘Improving Preventive Care for Patients w ith Low-health Literacy’’ Journal of Competent
Care 2012 May
‘‘Your Child ren’s Health’’ [weekly health column in The Goodville Press] 2009, 2010
‘‘How to u tilize quality measures to keep your patients out of the ED’’ Journal of Family
Medicine 2009 Dec
‘‘Managing chronic conditions through EHR tracking’’ Journal of Family Medicine 2009
Mar
‘‘How a potential lawsuit really affects your physician ’’ Journal of Law 2008 Oct
.
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Martina Diditright, MD: Application Packet
WELCOME LETTER FOR APPLICANTS
08/ 08/ 2013
Dear Dr. Did itright,
Thank you for your interest in becoming part of (name of health center) clinical staff. Prior to beginning your
service with (name of health center) you must complete our credentialing process and be approved by our board
of d irectors. The credentialing process involves evaluating a practitioner’s eligibility and competency for clinical
privileges. Our credentialing policy app lies to physicians, mid -level providers, and any licensed independent
healthcare practitioner who provides services in the (name of health center). All qualified applicants w ill receive
an application for medical staff membership and / or clinical privileges. We will make every effort to process your
application in a timely and efficient manner.
Credentialing is a five-step process:
Step 1. Applicant will receive the initial applicant packet
Step 2. Applicant will return completed applications along with requested documents
Step 3. Application will be reviewed and processed by our credentialing specialist to make sure all infor mation is
complete and accurate
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Step 4. The completed and verified applicant packet will be forwarded to the medical d irector to be presented to
the board of d irectors for approval
Step 5-. The Applicant will be notified of the board of d irectors’ decision
The credentialing process can take up to 90 to 120 d ays to verify, review, and obtain final app roval. To expedite
the process, your application should be without blanks or missing requested documents; if anything is missing,
the process will be delayed and could mean forfeiture of your privileges.
If at any time you have questions please contact ou r credentialing specialist at (phone number) or set up a
meeting to come to (name of health center) and go over your application prior to submission. Our goal is to assist
you to get on staff quickly while ensuring that we are compliant w ith Joint Commission and other relevant
guidelines.
Sincerely,
April Showers, MD
Medical Director
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CREDENTIALING APPLICATION
Please type or print responses legibly and in ink. Please complete the form in its entirety and attach all required
documentation. Incomplete applications will be returned to you and may result in a delay in the credentialing
process.
Supplementary d ocuments that must be completed and submitted include the following:
Affiliation Certification Letter
Three (3) Peer Reference Forms
Request for d elineation of Privileges
Professional Liability Claims History Form
Continu ing Medical Education (CME) Form
Attestation Statement
Please also submit the following with your app lication:
Curriculum vitae (CV)
Copy of medical/ professional license registration certificate
Copy of medical board certification
Other certificates (BLS, ACLS, ATLS, PALS, APLS)
Current Drug Enforcement Administration (DEA) registration
Current Controlled Dangerous Substances (CDS) registration
Copies of d iplomas (undergraduate, post-graduate, medical school, residency, fellowship)
Proof of professional liability insurance (policy declaration s page or letter from insurer)
Copy of most recent hepatitis B, MMR, and flu vaccination and tuberculosis PPD test
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Copy of government-issued picture identification
National Provider Identification number (NPI)
I. Demographic Information
Applicant Name: __Martina Did itright, MD______________________ SSN:123456789___________________ Address/ City/ State/ Zip:__1001 Garden Drive Healthy Town, Good State, USA _____________________ Phone: _000-123-456_________________Email: ____md id [email protected] ______Fax: _111-222-333_____ Date of Birth: _01/ 01/ 1965___ Place of Birth: Apple, USA__________________________________________ Gender: Male x Female Are you a United States Citizen? x Yes No If not a United States citizen, please check applicable box below: Work Permit (attach notarized copy) Visa Visa Type and Number: _________________
II. Professional/Licensure Information
Primary Practice Specialty:__Family Medicine_________________________________________Board Certified? x Yes No
Certifying Board:__American Board Family Medicine (1999, 2009), Emergency Medicine (2008)_______________________________
Certificate Number:__123/456_________Year Certified:___1999/2008_________
Last Year Recertified:__2009__________Expires:___2019/2018______________
Secondary Practice Specialty:Emergency Medicine_______________________________________Board Certified? X Yes No
Certifying Board:________________________________________________________________________________
Certificate Number:_____3456______Year Certified:_______2008_____
Last Year Recertified:_____________Expires:___2018______________
If not board certified , are you board eligible? Yes No Application d ate:_____________________
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Do you have a current Drug Enforcement Administration (DEA) license? x Yes No
License Number:_AD12340_______________________________Date of Expiration:__7/ 31/ 2016_________
Do you have a current Controlled Dangerous Substances (CDS) license? x Yes No
License Number:___5678_____________________________Date of Expiration:__12/ 31/ 2013_____________
Are you licensed to practice medicine in the state of (name of state)? x Yes No
Good State, USA (license no. 991122, expires 12/ 31/ 2014; Commonwealth of Urbanville (licensure no. 007008,
expires 08/ 31/ 2015)
Other Certifications (BLS, ACLS, ATLS, PALS, APLS)
Certification Certifying Organization Date Certified Date Certification Expires
ACLS American Heart Association 7/1/2000 12/31/2013
BLS 1996,97,98,99
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Professional History
Current Employer Address
Position
Full Time?
Part Time?
(include number
of hours per
week)
Date of Hire
(Month, Year)
03/12
Employment End
Date
Urbanville
Hospital Family
Practice Group
700 Main Street
Urbanville
Staff physician Yes 01/01/2011 07/31/2013
Previous
Employers
Address Position
Full Time?
Part Time?
(include number
of hours per
week)
Date of Hire
(Month, Year)
Employment End
Date
Wellness Hospital
100 Well Street, Pumpkintown Emergency
Physician
NO 24 01/2011
12/2011
Diditright Family
Practice
320 Well Street, Pumpkintown Family Practice
(owner;
physician)
YES 60 07/2002 12/2010
Goodville Family
Medical Center
600 Medical Center Drive,
Urbanville
Staff Physician Yes 45 07/1999 05/2002
Trick or Treat
Family Practice
400 Pumpkin Street,
Urbanville
Staff Physician YES 45 07/1999 05/2002
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Please provide the following information:
Yes No
Have you ever practiced under another name? If yes, what name?_________________________________________ x
Do you currently provide healthcare services in the state of (name of state)? x
Are you presently practicing in your specialty? x
Do you currently have active staff privileges at an accredited hospital? x
III. Insurance
Please attach proof of professional liability insurance, such as a policy declarations page or letter from insurer.
Name of Insurance Carrier:___Risky Business, Inc._____________Dates of Coverage:__2002- present_____
Full Address: __100 Malpractice Lane, Justice, USA _______________________________________________
Name of Previous Carrier(s):__DeepPocket, Inc._______________Dates of Coverage:__1999-2002________
Full Address: __007 Bond Drive, Fastlane, USA __________________________________________________
Name of Previous Carrier(s):_______________________________Dates of Coverage:____________________
Full Address: _________________________________________________________________________________
Has an insurance carrier denied , cancelled , or refused to renew your insurance coverage? Yes x No
(If yes, p lease attach a separate sheet with an explanation)
Have you ever had any professional liability claims brought against you? x Yes No
(If yes, p lease complete ‘‘Professional Liability Claims History Form ’’)
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IV. Education
Preprofessional Education
Name of School Address (City, State, Zip Code) Subject
Major/Minor
Years Attended Graduation Date
(Month, Year)
Degree
Urbanville College
99 President Blvd
Urbanville, USA
Chemistry;
Psychology
1988-92 5/92 BA (Magna Cum
Laude)
Professional Education
Name of School Address (City, State, Zip Code) Years Attended Graduation Date
(Month, Year)
Degree
University Medical College
1111 Jonas Salk Avenue
Small State USA
1992-96 06/96 MD
Residency Training and Fellowships (Post Graduation from Professional School)
Name of Institution Address (City, State, Zip Code) Specialty PG Level Date Completed
(Month, Year)
Total Number of
Months in Position
Goodville Hospital 123 Louis Pasteur Drive
Good State, USA
Family
Medicine
1-3 June 1999 36
Goodville Hospital Family
Practice Group
9999 Helen Keller Street
Green City, Good State
Family
Medicine
3 June 1999 6
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Teaching/Research Appointments
Name of Institution Address (City, State, Zip Code) Position Dates of Appointment (From/To)
Visiting Staff Appointments
Name of Institution Address (City, State, Zip Code) Position Dates of Appointment (From/To)
Wellness Hospital
222 Well Blvd
Ban, USA
Active staff 2010-present
Urbanville Hospital
100 Street Road
Urbanville, USA
Active Staff 2010-present
Goodville Hospital
100 Good Road
Goodville, USA
Active Staff 1999-2010 (until moved)
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V. References
Please list three professional references who can attest to the candid ate’s qualifications, clinical and professional
competence, mental competence, and character. At least one reference must be an attend ing or supervising
physician. Each reference must also complete the ‘‘Applicant Peer Request Form ’’ and return to (name of health
center).
1. Name:__May Day, MD___________________________Title:___ Director, Dept. Emergency Medicine Wellness Hospital__
Relationship to Candidate:____Former Supervisor______________________ ____________________________________
Address:___007 Bond Street, Urbanville, USA _____________________________________________________________
Phone: 444-444-4444___________Fax:________________________Email:[email protected]______________________
2. Name:__Abrahim Linkon MD ____________________________Title:__Director, Urbanville Family Practice Group __________
Relationship to Candidate: Former Medical Supervisor _________________________________________________________
Address:___007 Bond Street, Urbanville, USA ______________________________________________________________
Phone:___222-222-222________Fax:________________________Email:[email protected]____________________
3. Name:____Henry Cleanhands, RN_________________________Title: Director of Nursing Urbanville Hospital______________
Relationship to Candidate:__Co-Chair of Committee for Interdisciplinary Best Practices in Primary Care __________________________
Address _____007 Bond St, Urbanvville USA______________________________________________________________
Phone:__333-333-3333__________Fax:______________________Email: [email protected]__________________
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VI. Disciplinary Information
Please attach a separate sheet with an explanation for any ‘‘yes’’ answers
Yes No
Has your medical license ever been revoked, restricted, or suspended? x
Have your clinical privileges ever been revoked, restricted, or suspended? x
Has your membership on any medical staff ever been revoked, restricted, or suspended? x
Has your DEA license ever been denied or suspended? x
Have you ever been excluded from participation with Medicare or Medicaid program? x
Have you ever been requested to appear before a licensing agency (State Board of Examiner’s, Drug Enforcement Agency) for any reason?
The father of a pediatric patient who filed a lawsuit against me and other also lodged a complaint against me with the state medical board.
x
Have you ever been sanctioned by a federal or state agency? x
Have you ever been convicted of a felony or misdemeanor other than a minor traffic offense? x
Have you ever discontinued your practice (other than for vacation, education/training, maternity leave, or leave due to illness) for three
months or more?
x
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VII. Health Fitness
Please attach a separate sheet with an explanation for any ‘‘yes’’ answers
Yes No
Do you presently have any physical or mental condition, including alcohol or drug abuse, that may affect your ability to perform clinical or
professional duties?
x
Are you currently taking any medications that may affect your ability to perform clinical or professional duties? x
Do you have any communicable diseases? x
_x__ Please initial to certify that you are in good health and have no physical or mental cond itions that may affect
your ability to perform clinical or profession al duties.
Most recent physical exam performed by: Henrietta Cleanhands, MD__________Date: __06/ 01/ 2012___
Results of examination:____within normal limits__________________________________________________
VIII. Other Information
Yes No
Do you speak any other language other the English? If so, which language(s)
Fluent in the language Elsewhere
_____________________
_____________________
x
Are you presently or planning to reside within commuting distance to the Health Center? x
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AFFILIATION CERTIFICATION LETTER
Martina Did itright, MD____________________________________ Family Medicine___________________ Name of Applicant Specialty
To Whom It May Concern:
I have submitted an app lication for appointment/ reappointment to the staff of (name of health center). Please
complete the information below and return it d irectly to the address below. My signature authorizes you to
complete the form at my request. Thank you for your prompt attention to this request.
Sincerely,
Martina Diditright, MD 8/15/2013
____________________________________________________________________________________
Release of information signature/ d ate
Current Status:
____________________________________________________________________________________
Membership from _____________(date) to ______________(date)
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Yes No N/A
Have the practitioner’s privileges been restricted, suspended, or revoked? x
Have the practitioner’s privileges been reduced? x
Has the practitioner attempted procedures beyond his or her skill or training? x
Has the practitioner been the subject of disciplinary action by your organization or licensing body? x
Have the practitioner’s professional morbidity, mortality, infection, or complication rate exceeded your organization’s criteria for the
standard of practice?
x
Has the practitioner been suspended for medical record violations since the last appointment or reappointment? If yes, how many
times?___________
x
Has the practitioner’s behavior been disruptive to patient care? x
Have there been any written complaints about practitioner by patients, employees, or medical staff members? x
Has the practitioner been involved in a malpractice claim or lawsuit since the last appointment or reappointment? x
Is the practitioner compliant with organizational policies and medical staff bylaws? x
Does the practitioner have any physical, mental, emotional, or drug or alcohol dependence problems that may interfere with his or her
ability to perform professional and staff duties?
x
At the appropriate time, will you likely reappoint the practitioner to your medical staff?
Verification provided by:
Name:____Mary Poppins _________________________________________________
Signature:____Mary Poppins_________________________________________________
Date:____8/ 30/ 2013______________________________________________________
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Phone:____777-777-777____________________________________________________
Title:_____Credentials Coord inator_________________________________________
Fax:________________________________________________________
Institution Name:____Urbanville Hosp ital_________________________________________
Return Form to: Health Center, Address, City, State, ZIP phone # fax #
APPLICANT PEER REFERENCE FORM
Three (3) references are required for all applicants for appointment / reappointment.
Name of Applicant: Martina Did itright, MD
Specialty: Family Medicine
To Whom It May Concern:
I have submitted an app lication for appointment/ reappointment to the staff of the (name of health center). Please
complete the information below and return it d irectly to the address below. My signature authorizes you to
complete the form at my request. Thank you for your prompt attention to this request.
Sincerely,
__Martina Diditright, MD, 8/15/2013_________________________________________
Signature/ d ate
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Yes No
Does the practitioner demonstrate current clinical competence and provide appropriate care to patients? x
Does the practitioner demonstrate good diagnostic capabilities and good technical skills in the performance of invasive
procedures, if applicable?
x
Does the practitioner demonstrate effective communication skills with patients, families, and others involved in their care? x
To the best of your knowledge, does the practitioner have the appropriate mental and physical health to perform patient care
duties?
x
Have you observed or been informed of any physical or behavioral condition, including alcohol or drug dependence, related to
this applicant that has or reasonably may affect his or her ability to perform professional duties?
x
Does the practitioner maintain timely documentation of history and physical exams, progress notes, operative notes, narrative
summaries, etc.?
x
Does the practitioner make hospital rounds on a daily basis or as otherwise required and readily answer calls and consultations
when requested?
x
Does the practitioner exhibit personal integrity and adherence to professional ethics? x
Does the practitioner work well with others, communicate well with other providers, and have a good rapport with patients? x
What is your opinion regarding competency in performing the attached privileges? x
Are you aware of the practitioner being subjected to any disciplinary action by any licensing or certifying board or any
healthcare facility regarding medical staff membership and/or clinic privilege?
x
The above evaluation is based on (check all that apply):
Close observation of clinical performance xGeneral Impression Composite information from file Practitioner’s repu tation in the community Co-worker
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Recommendation:
xHighly recommend without reservation Recommend as qualified and competent Recommend with reservation Do not recommend
Signature:_______Donald Duck ____________________________________
Date:____09/ 02/ 2013_____________________________________________
Phone:____555-666-7777___________________________________________
Print Name:_Donald Duck, MD_____________________________________
Title:_____Emergency Physician_____________________________________
Fax:______________________________________________________________
Return Form to: Health Center, Address, City, State, ZIP phone # fax #
DELINEATION OF PRIVILEGES
Name of Applicant:___Martina Did itright, MD__________________________Specialty:_Family Medicine
Core Privileges1
Approved Proctoring
Required
Denied
Admit, evaluate, diagnose, treat, and provide consultation to
patients of all ages, with a wide variety of illnesses, diseases,
injuries, and functional disorders of the circulatory, respiratory,
endocrine, metabolic, musculoskeletal, hematopoietic,
gastroenteric, integumentary, nervous, female reproductive, and
genitourinary systems. May provide care to patients in the
intensive care setting in conformance with unit policies. Assess,
stabilize, and determine disposition of patients with emergent
conditions consistent with medical staff policy regarding
emergency and consultative call services.
x
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List Additional Procedures2 Approved Proctoring
Required
Denied
Applicant’s Signature/ Date:___ Martina Diditright, 8/15/2013___________________________________
Specialty Consultant Signature/ Date :___________________________________________(if applicable)
Medical Director Signature/ Date: __________________________________________________________
Medical Advisory Board Signature/ Date:____________________________________________________
Representative for Credentialing or Board Committee Signature/ Date:
Notes:
1. The American Academy of Family Physicians (AAFP) defines Core or Category I privileges as ‘‘uncomplicated ,
basic procedures and cognitive skills.’’ AAFP adds: ‘‘Physicians assigned to this category will be graduates of
approved medical/ osteopathic schools who are properly licensed and have demonstrated skills in family
medicine. Each request for privileges will be considered on an ind ividual basis and will require approval and
supportive documentation.’’ The health center should define Core or Category I privileges and skills necessary to
be granted these privileges.
2. Additional procedures, d efined by AAFP as Category II and Category III, are of increasing complexity and may
require add itional specific training, education, experience, and / or board certification as defined by the health
center. The health center should list each procedure that it w ill grant privileges for and the specific
documentation required of physicians to demonstrate that they meet privileging requirements.
For more information, see AAFP’s ‘‘Ambulatory Privilege Delineation Form for Family Physicians’’ at
http:/ / www.aafp.org/ online/ en/ home/ practicemgt/ privileges/ misc/ ambprivilege.html .
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PROFESSIONAL LIABILITY CLAIMS HISTORY FORM
The following is necessary to complete the credentialing verification process and will be kept confidential. Please
print or type answers to the following for any professional liability claims and lawsuits reported to your
professional liability insurance carrier, open or closed , settled or paid . Include only one case per sheet; copy this
form if needed for more than one case.
Provider Name:___Martina Did itright, MD_______________________________________________________
1. Plaintiff Name: Johnny B Goodenough Sr., representative of Johnny B. Goodenough Jr., a minor _______
Date of Birth:___________________________________ Age:___11_______
Name of patient involved :___Johnny B. Goodenough Jr .____________________________________________
Month and year of occurrence:___May 2000___________(event precipitating claim)
Month and year of claim or lawsuit:__May 2006________________________________
Insurance carrier time of claim:____Deep Pocket, Inc. _________________________________
2. What is/ was your status: Primary defendant x Co-defendant Other
Explain and list other defendants:
Defendants: Martina Did itright, MD; Jack Olantern, MD
I saw the patient in the office setting. The patient subsequently underwent surgery by Dr. Surgeon at Pumpkin
Hospital._______________________________________________________________________ =
What was the patient’s outcome?
Patient lost testicle. ___________________________________________________________________________
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Provide a summary of the allegations made against you.
The complaint stated ‘‘Alleged failure to timely d iagnose testicular torsion and refer minor plaintiff to hosp ital
emergency department or surgeon.’’____________________________________________________
What was your clinical role with regard to the patient?
I assessed the minor patient in the office setting for complaint of scrotal pain. The child ’s father d id not follow
my recommendation and instruction for immediate assessment in the hosp ital emergency department. But I d id
not document the recommendation in the patient’s record clearly to reflect the d ischarge instructions that I gave
to the child ’s father. Surgery performed by Dr. Surgeon was not successful. I believe that the verd ict was based
on sympathy for the child .
Current Status of Claim: (please check one)
Still pending as of d ate:_______________________
Name and address of your defense attorneys: Defense at Any Price Law Firm; Billy Hours, Esq.
Has a trial date been set? Yes No Trial Date __June ______________________
Settled out of court before trial? xYes No
Amount of settlement on your behalf $__100,000_(Dr. Surgeon also contributed to the settlement in amount
unknown to me)_________
Current status of lawsuit:
Dismissed : Date:_______________________
Defense Verd ict Date:_______________________
Plaintiff Verd ict Date:_______________________
Judgment Amount $:__________________________ Date:___________________
Amount of total judgment paid on your behalf $____100,000_____________________________
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This professional liability claim information form is required on all claims/ lawsuits that are reported by your
professional liability insurance carrier and / or the Nat ional Practitioner Data Bank. Clinical details are required
for all suits, regard less of status of settlement amount.
I certify that the information contained in this form is correct and complete to the best of my knowledge.
___Martina Diditright, MD_______________________________________________
Applicant’s Signature
Martina Did itright, MD_______________________________________________ Print Name __8/ 15/ 2013_________________
Date
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CONTINUING MEDICAL EDUCATION (CME) FORM
Please use this form to list current continuing medical education (CME) cred its earned within the last two years.
(name of health center) requires (number) of CME cred its. This form can be used in lieu of send ing copies of your
CME certificate(s). Please make as many copies of this page as needed .
Course Title Date Facility Address # CME
1. Using your EHR to improve patient care 07/2013 Ace Hospital 2
2. Utilizing Clinical Decision Support Tools
to Enhance Your Outcomes
05/2013 ABC 4
3. Family Medicine review
4. Cardiology
5. Medical record documentation and the
electronic medical record
07/2012
Cinamonville Hospital
12
9
3
6. Pediatric emergency care 06/2010 HealthyKids Hospital, USA 12
7. Challenges in the Care of the Diabetic
Patient
06/2008 Cinnamonville Hospital 9
8. Assessing Musculoskeletal Injuries 06/2007 Cinnamonville Hospital 4
9. Mental Health Disorders 06/2006 Mental Health Association of
Cinnamonville
3
10. Current Geriatrics 06/2005 Medical Society of
Cinnamonville
9
11. Dermatology Review 06/2004 Pumpkin Hospital 3
12. Gastroenterology Review 06/2003 GI Society of America 6
13. Legal Issues in Emergency Medicine 06/2002 Pumpkin Hospital 2
14.
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15.
16.
17.
18.
19.
20.
21.
22.
23.
I, ___Martina Did itright, MD__________________________ (print full name of the physician/ practitioner), agree,
as evidenced by my signature, that the information provided in this CME form is true and complete to the best of
my knowledge and that the omission or falsification of information may be cause of ineligibility or terminatio n
from medical staff membership
Applicant Signature:______Martina Diditright MD _________________________
Date:___08/ 15/ 2013_________________
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ATTESTATION STATEMENT
I, ____Martina Did itright, MD_________________________ (print full name of the physician/ practitioner), agree
as evidenced by my signature that the information provided in this application is true and complete to the best of
my knowledge and that the omission or falsification of information may be cause of ineligibility or terminatio n
from medical staff membership. I further agree that I have current professional liability coverage and I have
d isclosed the history of loss or limitation of privileges or d isciplinary action.
____ Martina Diditright MD ___________________8/15/2013_________________________
Applicant Signature Date
Martina Did itright, MD _________________________________________________________________ Print Name
All policies, procedures, and forms reprinted are intended not as models, but rather as samples submitted by ECRI Institute member and nonmember
institutions for illustration purposes only. ECRI Institute is not responsible for the content of any reprinted materials. Healthcare laws, standards, and
requirements change at a rapid pace, and thus, the sample policies may not meet current requirements. ECRI Institute urges all members to consult with
their legal counsel regarding the adequacy of policies, procedures, and forms.