Consultant Staff Application Form

Medicinal


Photo Requirements:

  • The image must be in JPG/JPEG file format
  • The image must be less than or equal to 500kB (kilobytes).
  • The image must be in blue background similar in tone to the sample above while the applicant must be in doctor's gown
Address


Note:

  • Required for the following specialties only: ANESTHESIOLOGY, PAIN MANAGEMENT, INTENSIVE CARE, PSYCHIATRY, EMERGENCY MEDICINE, NEUROLOGY
  • Other specialties may get S2 if applicable to them.
Specialization

MEDICAL EDUCATION
-
(As it appears in your certification)
INTERNSHIP
-
(As it appears in your certification)
PHILIPPINE BOARD OF MEDICINE

RESIDENCY
(As it appears in your certification)
FELLOWSHIP (Optional)
(As it appears in your certification)

CURRENT
A. Academic
B. Clinical

REFERENCE #1: Head of Department/Training
REFERENCE #2: Head of Department/Training


Privileging Instruction:


Below is the list of services the Medical Unit is offering that requires privileging.
  • Please tick the box of your requested privileges.
  • If you wish to request privileges other than those listed,please use the space provided under OTHERS.
  • The Medical Unit head will review your requested privileges and recommend action.
  • Final approval will come from the Medical Director and the President and CEO.

DISCLOSURE QUESTIONS
Licensure

Has your license to practice in your profession been restricted, suspended, revoked or voluntarily surrendered while under investigation or have you been subject to conditions or limitations by the Professional Regulation Commission(PRC)?

Have any formal or written complaints been filed against you with the Professional Regulations Commission(PRC)?

Have you ever received a reprimand or been fined by the Professional Regulations Commission(PRC)?

Have any formal or written complaints been filed against you with the Professional Regulations Commission(PRC)?

Has your S2 license/narcotic license or other controlled substances authorization been challenged, denied, revoked, suspended, not renewed or have proceedings toward any of those ends been instituted?

Hospital and Health Care Facility Privileges and Other Affiliations

Has your request for any specific clinical privileges been denied or limited, or have your clinical privileges at any Hospital or health care facility been limited, suspended, revoked, refused/denied, terminated, restricted, not renewed, relinquished (whether voluntarily or involuntarily) or subjected to probationary conditions or rare proceedings currently pending which may result in any such action?

Has your medical staff membership or appointment at any hospital or health care facility been denied, limited, suspended, revoked, not renewed, relinquished(whether voluntarily or involuntarily) or subjected to probationary conditions?

Has your professional employment ever been suspended, diminished, revoked or terminated at any hospital or health care facility or are any proceedings which may result in any such action currently pending?

Have you ever withdrawn(or voluntarily relinquished) your application for appointment, re-appointment or privileges or resigned from the medical staff because disciplinary action or loss or restriction of clinical privileges was threatened or before a decision about your appointment and/or privileges was rendered by a hospital or health care organization's governing board?

Have you ever been the subject of disciplinary action or proceedings at any health care facility?

Have you ever been reprimanded, censured, excluded, suspended, and/or disqualified from participating, or voluntarily withdrawn to avoid an investigation in Philhealth and/or any government health-related programs and agencies?

Have you ever been suspended, sanctioned or restricted or been subject to any disciplinary action, by any managed care organizations such as Health Maintenance Organization (HMO) or other prepaid health care plan?

Has your application for membership as a participating provider has been rejected by any HMO or other prepaid health care plan or your contract as a participating provider terminated by any HMO or other prepaid plan?

Conflict of Interest

Do you have financial interest (directly or through family or business partners) in any hospital, clinic, nursing home, laboratory, pharmacy, medical equipment or supply house or other business to which patients from this facility might be referred or recommended?

Membership in Organization/Society

Have you been denied membership or renewal thereof in any local or national medical organization or professional society?

Have you ever been disciplined, suspended, reprimanded sanctioned, censured or restricted in any local or national medical organization or professional society or have proceedings toward any of those ends been instituted?

Malpractice and Professional Liability Insurance Information

Have you ever had any malpractice actions (pending, settled, dropped, dismissed, arbitrated, mediated, or litigated)? If yes, please provide information for each case (list each action separately)

Criminal/Civil History

Have you ever been convicted or, pled guilty to any felony in the last 3 years or been found liable or responsible or named as a defendant in any civil offense that is reasonably related to your qualifications, competence, functions or duties as a medical professional?

Have you ever been convicted or pled guilty to any felony in the last 3 years or been found liable or responsible or named as a defendant in any civil offense that may include but is not limited to alleged fraud, an act of violence, child abuse or a sexual offense or sexual misconduct?

Have you ever been indicted in any civil or criminal suit?

Ability to Perform Job

Are you unable to perform essential functions of the position for which you have applied or of the privileges you have requested, with or without a reasonable accommodation, according to accepted standards or professional performance and without posing a direct threat to patient or staff?

Do you have a medical condition, physical defect or emotional impairment which in any way impairs and/or limits your ability to practice medicine with reasonable skill and safety?

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

Do you currently overuse and/or abuse alcohol or any other controlled substances?

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