Docstoc

DHP Packet

Document Sample
DHP Packet Powered By Docstoc
					                         Midwest Division
  Dependent Healthcare Professional
                              (DHP)




                           Packet A
                 (DHP to complete & return)




Parallon Workforce Management Solutions (formerly All About Staffing, Inc.)
  1000 Sawgrass Corporate Parkway • Sixth Floor • Sunrise, FL • 33323
                                                                       

 

Dear Dependant Healthcare Professional (DHP): 

Thank you for your interest in providing services at HCA Facilities.  In keeping with requirements of 
The Joint Commission, the Centers for Medicare and Medicaid Services (CMS), Accreditation 
Association for Ambulatory Healthcare (AAAHC), and State regulatory agencies, we require each 
person who is requesting permission to provide services within the HCA Facilities to undergo a 
process to verify that they have the qualifications and competence to provide those services safely 
and meet applicable, evidence‐based quality standards.   

Parallon Workforce Management Solutions is the official credentialing verification organization for 
HCA and we will be managing the tracking and monitoring of all DHP credentials.  To expedite the 
processing of your request please complete the attached application Packet A. The credentialing 
fee is $250.00 biennially and once Packet A is fully completed and all supporting materials 
are received along with payment the process will take 7­10 business days. Packet B is 
informational and educational only, please review and keep for your records. If you have any 
questions about the application process, please do not hesitate to call. 
 
Please return the documents by U.S mail, fax, or email.  

The address is: 
Parallon Workforce Management Solutions 
Attn: DHP Credentialing 
1000 Sawgrass Corporate Parkway  
6th Floor 
Sunrise, FL  33323 

Thank you in advance for your cooperation.  

Sincerely,  

DHP Credentialing Team 
AAST.DHPCredentialing@hcahealthcare.com 
(954) 514‐1440 
1‐800‐737‐8661 ext 1440 
(866) 361‐2812 (secure e‐fax)     

 
              DHP CREDENTIAL CHECKLIST 
                                    PLEASE MAKE SURE ALL REQUIRED FORMS ARE SENT 
 
          Application 
 

          Delineation Scope of Service Form 
 

_____Letter of Compliance (Letter/Certificate from your company stating you are up to date                       
                                                       with training/services as it pertains to your position) 
 
_____ Job Description & References 
 
          Experience Documentation Form  

         AORN (if applicable – OR/Aseptic Techniques Certificate or Letter of training for OR Access)  

_____ HIPAA (Letter or Certificate) 

_____BLS/ACLS (if applicable) 

_____ Copy of Professional License or Certificate (if applicable) 
 
_____Certificate of Insurance (Requirements included in packet) 
 
          Background Inquiry Requirements Form 
 
          Photo ID (required for identification purposes only) 
 
          PPD (form from your doctor with your TB results) * provide Chest X‐Ray if PPD is 
                    positive* 
 
_____MMR (if applicable‐ records or titers) 
 
          Influenza (if you are consenting or declining) –required from October to March 
 
______Drug Screen (if applicable) 
                      
          Acknowledgement Form 
 
          Confidentiality and Security Form  
 
          Payment Form (Provide a $250.00 (biennially) processing fee by company check (payable to All  
                                                About Staffing Inc.) or credit card 
                                                                                  
                                                                                 
                                                                                 
               PLEASE CONTACT ANY DHP CREDENTIALING SPECIALIST WITH ANY QUESTIONS OR CONCERNS 
                        AAST.DHPCREDENTIALING@hcahealthcare.com 
                1‐800‐737‐8661 x 1440(main line)    (866) 361‐2812 (secure e‐fax) 
Dependent Healthcare Professional (DHP) APPLICATION for Presence in Midwest Division HCA Facilities
(Allen County Hospital, Centerpoint Medical Center, Lafayette Regional Health Center, Lee's Summit Medical Center, Menorah Medical Center,
 Overland Park Regional Medical, Research Belton Hospital, Research Medical Center, Research Psychiatric Center, Centerpoint Ambulatory Surgery Center, Mid-
America Surgery Institute, Overland Park Surgery Center, SurgiCenter of Johnson County, SurgiCenter of Kansas City), Midwest Physician Practices
                                                                            Page 1 of 2

Name: _________________________________________________________________________________________
                     Last                                                    First                                    Middle

Vendor/ Physician name: ________________________________________ Company Phone: _________________________

Company Address: ________________________________________________________________________________
                                            Street                    City                            State                        Zip



DHP Office Phone: __________________ DHP Cell Phone: ___________________ DHP Fax:

E-Mail Address: __________________________________________________________________________________________

DHP Type (ex. Dialysis nurse; Surgical Tech; HCIR; Perfusionist): _________________________________________________

Professional License - State and Number: (ex. RN) __________________________________________________________________

School of Professional Degree (if licensed in healthcare profession ex. RN): ___________________________________ Year of Degree: ______

As a Dependent Healthcare Professional (DHP), I am requesting approval to provide services at the following Midwest Division
HCA Hospitals, Ambulatory Surgery Centers and Physician Practices: (check all applicable)


          Facilities                                            Surgery Centers                                      Physician Practices

        Allen County Hospital                                   Centerpoint Ambulatory Surgery                          Midwest Metropolitan Physicians
        Centerpoint Medical Center
                                                                   Center                                                  Group

        Lafayette Regional Health Center
                                                                 Mid-America Surgery Institute

        Lee's Summit Medical Center
                                                                 Overland Park Surgery Center

        Menorah Medical Center
                                                                 SurgiCenter of Johnson County

        Overland Park Regional Medical
                                                                 SurgiCenter of Kansas City

        Research Belton Hospital
        Research Medical Center
        Research Psychiatric Center




         Patient Care Areas (check all applicable)

        Cath Lab                                                             Pharmacy
        Endoscopy Lab                                                       Respiratory
        Operating Room                                                      Nursing Stations (ICU, NSY, Med Surg)
        Radiology Department                                                 Other:_________________________________
         ER
Dependent Healthcare Professional (DHP) APPLICATION for Presence in Midwest Division HCA Facilities
(Allen County Hospital, Centerpoint Medical Center, Lafayette Regional Health Center, Lee's Summit Medical Center, Menorah Medical Center,
 Overland Park Regional Medical, Research Belton Hospital, Research Medical Center, Research Psychiatric Center, Centerpoint Ambulatory Surgery Center, Mid-
America Surgery Institute, Overland Park Surgery Center, SurgiCenter of Johnson County, SurgiCenter of Kansas City), Midwest Physician Practices
                                                                            Page 2 of 2




1. Responsibilities of DHP:
   I understand I must:
      a. Provide Parallon Workforce Management Solutions Regional office (where I am submitting this application) with my
          consent and all information requested to conduct a criminal record background investigation;
      b. Provide proof of health requirements;
      c. Pledge that I will not participate in any patient care services if I have symptoms of any contagious disease or condition;
      d. Receive and acknowledge review of the primary Facility’s Safety and HIPAA Policies & Procedures;
      e. Provide proof of general liability, professional services errors and omissions and product liability insurance;
      f. Submit a non-refundable processing fee of $250.00 biennially to cover cost of the above verifications for all Midwest HCA
          Facilities;
      g. Contractual agreement for the Midwest Division facilities will be for 2 years
      h. Sign and return Code of Conduct Acknowledgement Card;
      i. Wear a Photo ID with Company Reference at all times while in a facility;
      j. Check in with Materials Management (or other designated area) upon each visit to a facility;
      k. Sign Confidentiality Agreement


2. Parallon Workforce Management Solutions responsibilities:
    The Parallon Workforce Management Solutions Regional Office where the application is submitted will:
      a. Verify the identity of the applicant by obtaining copy of a government-issued photo ID;
      b. Verify the documents required as outlined in the HCA DHP Policy and Delineation of Scope of Service & Qualifications;
      c. Order the criminal background investigation Level II (Facilities have the right to deny approval based on results of this
          report);
      d. Query the Office of Inspector General (OIG); General Services Administration (GSA); *the State Department of Health;
          *State Licensing Agency; and the *National Practitioner Data Bank (*if the DHP is a licensed healthcare professional).

3. Midwest Division Facilities’ responsibilities:
     a. Obtain approval from Facility Administration and notify the DHP and appropriate facility staff of the approval for the DHP
        to be present during procedures in the appropriate settings;
     b. Establish DHP Orientation; and
     c. Complete Annual Evaluation of Performance.

4. Acknowledgments/Attestations:
      a. I have received a copy of the Policy for “Credentialing of Dependent Healthcare Professional (DHP)” and understand that
         in making application to provide services at any HCA Midwest Division Facility, I agree to comply with all Facility
         policies, including provisions of the medical staff bylaws and rules & regulations, which apply to the provision of services
         that I am requesting.
      b. I understand that any of the Midwest Division Facilities and/or Parallon Workforce Management Solutions may deny
         approval or revoke any approval it grants to me to attend procedures at any time without any due process.
      c. I attest that all information provided in this application is true and correct, and I understand that misrepresentation of
         information during the application process may disqualify me from providing services at any HCA Midwest Division
         Facility.
      d. I agree to allow authorized representatives of Parallon Workforce Management Solutions to request the information needed
         to verify my qualifications and competence, and give permission to the authorized representatives of my Company, other
         Facilities where I provide services, and any other third parties to release this information upon request.



Signature of DHP (Vendor):________________________________________ Date: _________________
                      Delineation of Scope of Services & Qualifications
For purposes of this request, the term “product” refers to any device, equipment, medical system, drug or any other
FDA-regulated product which you are promoting, selling, providing training or services as described below.

Please select the Tier of services you are requesting by initialing the Tier and checking the specific services to be
provided. Services shall not be provided until you are notified of approval.

*Healthcare Industry Representatives (HCIR’s) are not permitted to provide hands on care to any patients.*



 Tier 2       Descr iption
              I request to provide services that require access to a patient care area. The services I provide may have
              indirect impact on patients and /or hands-on care which will require supervision from a member of the
              clinical staff of the facility (i.e. CNO/CNO designee) during any service at the facility. Services I am
              requesting to provide include the following (check all that are being requested):
              
              Deliver product to a patient care setting (e.g., nursing care unit)
              Repair or maintain a product
              Provide user training and product support
              Provide clinical assessment/care in a patient care setting

              Credentials Required:
                  o    Provide evidence of current licensure, certification or registration when required by law or
                       regulation to practice in your profession
                  o    Provide copy of a current photo id
                  o    Provide evidence of training for all of the following:
                               Certificate or confirmation on company letterhead that attests to the training in
                                the medical system, device, treatment, procedure or drug for which approval is
                                sought
                               Evidence of completion of an Operating Room protocols course (such as the
                                AORN course), to include:

                                     •    The Joint Commission Universal Protocol and AAAHC

                                     •    Aseptic principles and techniques

                                     •    Appropriate donning and wearing of surgical attire

                                     •    Fire prevention as related to heat sources

                                     •    Sterile fields and traffic patterns


                               Training in infection control practices, specifically to include use of PPE,
                                standard precautions, and hand hygiene procedures as defined by CDC or WHO




                                                     Page 1 of 4
Tier 2   Descr iption
                          Training in bloodborne pathogens precautions.
                          Training in fire, electrical and other safety protocol.
                          Training in patient rights, specifically to include confidentiality, HIPAA
                           compliance requirements, and requirements related to human subject
                           experimentation if you shall be providing services in conjunction with a product
                           that is experimental or “off-label” as defined by the FDA
                          Training in patient safety, specifically to include National Patient Safety Goals,
                           and procedures for reporting concerns about patient safety or quality of care
             o    Provide documentation of experience, specifically to include:
                          Letter of reference & job description
                          Evidence of having provided product support or services similar to what is being
                           requested on at least five (5) occasions in the last 12 months
             o    Provide documentation of applicable health screening and vaccinations, including:
                          Tuberculosis testing
                          Influenza and other vaccinations as required by the Facility {specify}
                          By submitting an application, you agree not to participate in the delivery of
                           services when experiencing symptoms of a contagious disease
             o    Provide proof of professional services errors and omissions insurance in the amounts of $1
                  million/$3 million, or an acceptable alternative as specified in the DHP Policy
             o    Submit a signed Facility Confidentiality and Security Agreement, or an acceptable
                  alternative as specified in the DHP Policy
             o    Consent for a Criminal background check


Tier 3   Descr iption
         I request to provide services that require access to patient care areas. I will provide clinical services
         and/or direct hands on care which will require the involvement and supervision of a physician or other
         licensed independent practitioner (LIP). Services I am requesting to provide include the following
         (check all that are being requested):
         
         Deliver product to a procedural area (e.g., OR, cath lab)
         Demonstrate product usage on a patient
         Provide technical training to clinicians regarding the product
         Assist with clinical care in product use or set-up including calibration or performing as the primary
           user of the product in the care of a patient
          Assist with clinical care in a procedural / patient care area ( e.g., OR, cath lab)
         Specify the device(s), equipment, or systems to be used in the provision of services:
         ___________________________________________________________________

         Specify the operative or invasive procedure(s) involved in the provision of services:
         ___________________________________________________________________



                                                Page 2 of 4
Tier 3   Descr iption
         ___________________________________________________________________

         Credentials Required:
            o   Provide evidence of current licensure, certification or registration when required by law or
                regulation to practice in your profession
            o   Provide evidence of formal education (e.g., copy of degree, certificate, or equivalency)
            o   Provide copy of a current photo id
           o    Provide evidence of training for all of the following:
                        Evidence of completion of an Operating Room protocols course (such as the
                         AORN course), to include:

                             •    The Joint Commission Universal Protocol and AAAHC

                             •    Aseptic principles and techniques

                             •    Appropriate donning and wearing of surgical attire

                             •    Fire prevention as related to heat sources

                             •    Sterile fields and traffic patterns
                        Training in the medical system, device, treatment, procedure or drug for which
                         approval is sought
                        Training in infection control practices, specifically to include use of PPE,
                         standard precautions, and hand hygiene procedures as defined by CDC or WHO
                        Training in bloodborne pathogens precautions.
                        Training in fire, electrical and other safety protocol.
                        Training in patient rights, specifically to include confidentiality, HIPAA
                         compliance requirements, and requirements related to human subject
                         experimentation if you shall be providing services in conjunction with a product
                         that is experimental or “off-label” as defined by the FDA
                        Training in patient safety, specifically to include National Patient Safety Goals,
                         and procedures for reporting concerns about patient safety or quality of care
           o    Provide documentation of experience, specifically to include:
                        Letter of reference & job description
                        Evidence of having provided product support or services similar to what is being
                         requested on at least five (5) occasions in the last 12 months – must include the
                         same procedures and devices/equipment specified above
           o    Provide documentation of applicable health screening and vaccinations, including:
                        Tuberculosis testing
                        Influenza and other vaccinations as required by the Facility {specify}



                                             Page 3 of 4
 Tier 3    Descr iption
                          By submitting an application, you agree not to participate in the delivery of
                           services when experiencing symptoms of a contagious disease


               o   Provide proof of professional services errors and omissions insurance in the amounts of $1
                   million/$3 million, or an acceptable alternative as specified in the DHP Policy
               o   Submit a signed Facility Confidentiality and Security Agreement, or an acceptable
                   alternative as specified in the DHP Policy
               o   Consent for a Criminal background check



 Cardiac Catheterization Lab                    Pharmacy
Endoscopy Lab                                  Respiratory
 Operating Room                                 Nursing Station( specify i.e. ICU)_________________
 Radiology Department                            Other: ______________________
 ER (Emergency Department)



DHP Printed Name: ___________________________Company/Vendor: __________________

DHP Signature: _______________________________Date: ________________________




Facility Use Only – (Parallon Workforce Management Solutions will obtain the signatures)
Facility Name:
Director Signature:                                                 Area:                           Date:
Director Signature:                                                 Area:                           Date:
Medical Staff Signature (Tier 3 only):                              Date:

Administrator Signature (if applicable):                            Date:




                                               Page 4 of 4
                                        
 



                       Training Requirements 
 
 
Letter of compliance:  
 
       A letter, a statement, or certificate from your company that attests to your training and 
        competency on the medical system, device, treatment procedure, drug or service you are 
        providing at the facility. Letter must attest to current employment 
         
       Evidence of having provided experience documentation on five (5) occasions in the last 12 
        months, see next page, can be included in letter of compliance 
 
Credentials Required: 
       Provide evidence of current licensure, certification or registration when required by law or 
        regulation to practice in your profession (e.g., RN license, ACLS, BLS certification)  
       Provide evidence of formal education (e.g., copy of degree, certificate, or equivalency) 
       Provide evidence of training for all of the following when applicable: 
              Evidence of completion of an Operating Room protocols course when OR access is 
               required (such as the AORN course), to include: 
                   ‐   The Joint Commission Universal Protocol and AAAHC 
                   ‐   Aseptic principles and techniques 
                   ‐   Appropriate donning and wearing of surgical attire 
                   ‐   Fire prevention as related to heat sources 
                   ‐   Sterile fields and traffic patterns 
              Training in the medical system, device, treatment, procedure or drug for which 
               approval is sought 
              Training in infection control practices, specifically to include use of PPE, standard 
               precautions, and hand hygiene procedures as defined by CDC or WHO 
              Training in bloodborne pathogens precautions. 
              Training in fire, electrical and other safety protocol. 
              Training in patient rights, specifically to include confidentiality, HIPAA compliance 
               requirements, and requirements related to human subject experimentation if you 
               shall be providing services in conjunction with a product that is experimental or 
               “off‐label” as defined by the FDA 
              Training in patient safety, specifically to include National Patient Safety Goals, and 
               procedures for reporting concerns about patient safety or quality of care 
                                         

                   
Experience Documentation Requirements 
 
      The  Experience  Documentation  form  is  required  to  verify  that  Dependent 
      Healthcare Professionals are using current trained skills within the last 12 months 
      in a facility.   
       
Please provide: 

      Evidence of having provided services on five (5) occasions in the 
      last 12 months. Experience Documentation must demonstrate the 
      current services that you will be providing at HCA facilities 
               
             Proof of evidence examples: 
               
              a. A letter from your present company stating you have provided services on five 
                 (5) occasions in the last 12 months in any facility. The letter must include the 
                 type of service provided, the physician/clinician/staff you worked with, the area 
                 that you provided the service, the date of service and the name of facility. 
                    
              b. Five (5) Invoices with service information (e.g., date, name of physician, etc.)  
                   Per HIPAA policy please make sure patient information is not included on invoice. 
                    
              c.   Experience Documentation Form‐  included in packet (Fully completed) 
               
                    
                    
       
 
                                  Experience Documentation Form
         DHP Printed Name:________________________                               DHP Company Name_______________________

         In accordance to the instructions contained in the DHP Credentialing Policy pertaining to the experience documentation,
         I hereby affirm that the above mentioned Dependent Healthcare Professional has provided services 
         and has met the requirements set forth by HCA.

         Date                    Facility Physician or Clinician  Printed Name   Facility Physician or Clinician Signature
Case 1




         Facility                Patient Care Area                               Service or Technical Support on Medical Device/Product


         Date                    Facility Physician or Clinician  Printed Name   Facility Physician or Clinician Signature
Case 2




         Facility                Patient Care Area                               Service or Technical Support on Medical Device/Product


         Date                    Facility Physician or Clinician  Printed Name   Facility Physician or Clinician Signature
Case 3




         Facility                Patient Care Area                               Service or Technical Support on Medical Device/Product


         Date                    Facility Physician or Clinician  Printed Name   Facility Physician or Clinician Signature
Case 4




         Facility                Patient Care Area                               Service or Technical Support on Medical Device/Product


         Date                    Facility Physician or Clinician  Printed Name   Facility Physician or Clinician Signature
Case 5




         Facility                Patient Care Area                               Service or Technical Support on Medical Device/Product


I attest that all information provided is true and correct, and I understand that misrepresentation of information may disqualify me 
from providing services at any HCA Facility.
                                                                                                   ______________________________________________
                                                                                                                DHP Signature
                          Background Inquiry Requirements
HCA requires that all DHP’s undergo a level 2 background search. Once your application packet is
returned and payment is received, we will send you a link to upload your personal information for
background verification. This is a confidential and secure link to GIS (General Information Services). It is
vital that you complete the consumer authorization requirements in a timely manner, failure to do so
will result in a delay in your ability to work in a HCA facility.

The report that Parallon Workforce Management Solutions will receive from GIS will include information
as to your character, work habits, performance and experience along with reasons for termination of
past employment from previous employers. Please understand that you will be required to provide
specific data that will generate information from federal, state and other agencies which maintain
records concerning your past activities relating to your driving, criminal, worker’s compensation, civil
and other experiences.

A Level 2 background check consists of the following; Social Security Number Verification, 7 years
Criminal History Search, 7 years Employment Verification, OIG List of Excluded Individuals, GSA
Quarterly Verification, Government Suspect List, Education Verification, Violent Sexual Offender and
Predator Registry Search, Professional Medical License Verification if applicable.

Once all information has been submitted to GIS the background process will take 5-7 business days
(with all documents submitted). You will not be compliant to work in any HCA facility until this
process is complete.

___________________________________________________________________________________________
 I hereby consent to Parallon Workforce Management Solutions obtaining the above information from licensed
agents. I understand to aid in the proper identification of my file or record the above information, as well as other
information, is necessary.

Print Name __________________________                 Today’s Date _________________________

Signature ___________________________                 Date of Birth ________________________


Social Security Number _______________________


Home Address________________________________________________________________

City, State and Zip_____________________________________________________________
                  Health Form Requirements 


    Please provide documentation of applicable health screening and 
                       vaccinations, including: 
 
 

     PPD ­ Tuberculosis testing required yearly 
         If  you  received  a  positive  (+)  TB  result,  please  provide 
         Parallon Workforce Management Solutions with a chest x‐ray 
         and request a TB Questionnaire 
      
      
     MMR – Shot Records or Titers 
                    
                    
      
     Influenza  vaccine  consent  or  decline  forms  required 
         during flu season (October thru March) 
                   
PLEASE ONLY COMPLETE IF YOU RECEIVED A POSITIVE TB RESULT ALONG WITH A RECENT CHEST XRAY


EMPLOYEE NAME: _______________________________                    DATE: ___________

COMPANY NAME: ____________________________________


 If you have had a positive PPD in the past, go to step II. If you receive PPD’s on an annual
basis, complete Step 1 ONLY.

DATE OF LAST PPD: _____________ RESULTS OF LAST PPD IN MM: ___________

STEP II
Since you have had a positive/sensitive PPD and are no longer required to have an annual
chest x-ray, the following is to be completed annually and maintained in the personnel file.
However, you must have the results of at least one XRAY on File.

DATE OF LAST XRAY: _____________

Please read and put a checkmark in the correct Yes/No space if you are experiencing any
of the following symptoms or if any of the following apply to you:
                                                                   YES NO
1. Unplanned loss of weight(>10% of body weight)…………………… ___ ___
2. Nightsweats…………….………………………………………………. ___ ___
3. Fever lasting several weeks ..……………………………………….. ___ ___
4. Frequent coughing in the absence of a cold or flu…………………. ___ ___
5. Coughing blood-streaked sputum………………………………..……___ ___
6. Unusual tiredness or weakness lasting weeks ………….………….___ ___
7. Pain in chest when taking a breath………………………………….. ___ ___
8. Have you been recently diagnosed with diabetes, silicosis, HIV
   disease, renal disease or liver disease?………………………………___ ___
9. Have you been recently been exposed to a family member or
   others with active TB?…………………………………………………………………………....___ ___

 If you checked YES to any of the above question, are you currently treating with a physician?:
(Circle one) YES NO Please explain:_____________________________________________
_________________________________________________________________________________
___________________________________________________________

IF YOU DEVELOP ANY OF THE SYMPTOMS LISTED ABOVE, PLEASE CONTACT YOUR PHYSICIAN AND
AGENCY IMMEDIATELY. A CHEST X-RAY MUST BE PERFORMED PRIOR TO WORKING AGAIN.



SIGNATURE: _______________________________                     DATE: _______________
          PLEASE HAVE YOUR COMPANY REVIEW THIS BEFORE
                  SENDING ANY INSURANCE FORMS
     DHP Insurance Requirements in accordance with the HCA Guidance Policy:

1)   Proof of professional services errors and omissions coverage in the minimum amount of one million
     dollars per occurrence and three million dollars annual aggregate. Acceptable alternatives are written
     proof (e.g., a copy of the certificate of insurance or a letter with a copy of an endorsement naming the
     DHP as an additional insured) of the following:

     a)    The DHP has been added to the manufacturer's Products Coverage as an additional insured, or the
           products coverage has been modified to delete any exclusion for instructions, demonstrations,
           installation, service, and repair operations by an DHP.

     b)    If the General Liability coverage includes products and completed operations, the General Liability
           has been endorsed to include the DHP as an additional insured. This policy may also need to be
           modified to delete any exclusion for demonstrations, instructions, installation, service or repair of
           the DHP.

     c)    The manufacturer may also be self-insured. If the company does not have a certificate of insurance
           naming the DHP as an additional insured, they must provide a letter describing their self-insurance
           coverage, the limits offered, and specifically name the DHP as an additional insured. Self-insurance
           options should be reviewed by the Insurance department at Health Care Indemnity, Inc.

           Certificate Holder should be listed as:
           HCA – Midwest Division
           c/o Parallon Workforce Management Solutions
           1000 Sawgrass Corporate Parkway
           Sunrise, FL 33323

           Types of Business Liability Insurance

           General Liability Insurance: This form of business liability insurance is the main coverage to
           protect a business from: injury claims, property damages, and advertising claims. General liability
           insurance also known as Commercial General Liability (CGL).

           Professional Liability Insurance: Business owners providing services will need to consider
           having professional liability insurance known as errors and omissions. This coverage protects a
           business against malpractice, errors, negligence and omissions. Depending on a profession, it may
           be a legal requirement to carry such a policy. Doctors require coverage to practice in certain states.
           Technology consultants often need coverage in independent contractor work arrangements.

           Product Liability Insurance: Businesses selling or manufacturing products should be protected in
           the event of a person becoming injured as a result of using the product. The amount of coverage
           and the level of risk depends on business type.

           PLEASE HAVE YOUR COMPANY OR INSURANCE CARRIER CONTACT ANY DHP
           CREDENTIALIST WITH ANY QUESTIONS OR CONCERNS.

Thank you in advance for your cooperation.

Sincerely,
DHP Credentialing Team
AAST.DHPCredentialing@hcahealthcare.com
800-737-8661 x 1440
                         Vendor Confidentiality and Security Agreement
I understand that the HCA affiliated facility or business entity (the “Company”) for which I provide services, manages health
information as part of its mission to treat patients. Further, I understand that the Company has a legal and ethical
responsibility to safeguard the privacy of all patients and to protect the confidentiality of their patients’ health information.
Additionally, the Company must assure the confidentiality of its human resources, payroll, fiscal, research, internal reporting,
strategic planning information, or any information that contains Social Security numbers, health insurance claim numbers,
passwords, PINs, encryption keys, credit card or other financial account numbers (collectively, with patient identifiable
health information, “Confidential Information”).
          In the course of my assignment at the Company, I understand that I may come into the possession of this type of
Confidential Information. I will access and use this information only when it is necessary to perform my job related duties in
accordance with the Company’s Privacy and Security Policies, which are available on the Company intranet (on the Security
Page) and the Internet (under Ethics & Compliance). I further understand that I must sign and comply with this Agreement in
order to obtain authorization for access to Confidential Information or Company systems.

     General Rules
    1.   I will act in accordance with the Company’s Code of Conduct at all times during my relationship with the
         Company.
    2.   I understand that I should have no expectation of privacy when using Company information systems. The
         Company may log, access, review, and otherwise utilize information stored on or passing through its systems,
         including email, in order to manage systems and enforce security.
    3.   I understand that violation of this Agreement may result in disciplinary action, up to and including termination
         of privileges, and/or termination of authorization to work within the Company facility or with Company data.

     Protecting Confidential Information
    4.   I will not disclose or discuss any Confidential Information with others, including friends or family, who do not
         have a need to know it. I will not take media or documents containing Confidential Information home with me
         unless specifically authorized to do so as part of my job.
    5.   I will not publish or disclose any Confidential Information to others using personal email, or to any Internet
         sites, or through Internet blogs or sites such as Facebook or Twitter. I will only use such communication
         methods when explicitly authorized to do so in support of Company business and within the permitted uses of
         Confidential Information as governed by regulations such as HIPAA.
    6.   I will not in any way divulge, copy, release, sell, loan, alter, or destroy any Confidential Information except as
         properly authorized. I will only reuse or destroy media in accordance with Company Information Security
         Standards and Company record retention policy (provided upon request).
    7.   I will not make any unauthorized transmissions, inquiries, modifications, or purgings of Confidential
         Information.
    8.   I will not transmit Confidential Information outside the Company network unless I am specifically authorized
         to do so as part of my job responsibilities. If I do transmit Confidential Information outside of the Company
         using email or other electronic communication methods, I will ensure that the Information is encrypted
         according to Company Information Security Standards (provided upon request).

     Following Appropriate Access
    9.  I will only access or use systems or devices I am officially authorized to access, and will not demonstrate the
        operation or function of systems or devices to unauthorized individuals.
    10. I will not attempt to bypass Company security controls.
    11. I will only access software systems to review Company information when I have a business need to know, as
        well as any necessary consent. By accessing Company information, I am affirmatively representing to the
        Company at the time of each access that I have the requisite business need to know and appropriate consent,
        and the Company may rely on that representation in granting such access to me.

     Using Portable Devices and Removable Media
    12. I will not copy or store Confidential Information on removable media or portable devices such as laptops,
        personal digital assistants (PDAs), cell phones, CDs, thumb drives, external hard drives, etc., unless
        specifically required to do so by my job assignment. If I do copy or store Confidential Information on
        removable media, I will encrypt the information while it is on the media according to Company Information
        Security Standards (provided upon request).
6/2011
    13. I understand that any mobile device (Smart phone, PDA, etc.) that synchronizes Company data (e.g., Company
        email) may contain Confidential Information and as a result, must be protected. Because of this, I understand
        and agree that the Company has the right to:
            a. Require the use of only encryption capable devices.
            b. Prohibit data synchronization to devices that are not encryption capable or do not support the required
                 security controls.
            c. Implement encryption and apply other necessary security controls (such as an access PIN and
                 automatic locking) on any mobile device that synchronizes company data regardless of it being a
                 Company or personally owned device.
            d. Remotely "wipe" any synchronized device that: has been lost, stolen or belongs to a terminated
                 employee or affiliated partner.
            e. Restrict access to any mobile application that poses a security risk to the Company network.

     Doing My Part – Personal Security
    14. I understand that I will be assigned a unique identifier (e.g., 3-4 User ID) to track my access and use of
        Confidential Information and that the identifier is associated with my personal data.
    15. I will:
             a. Use only my officially assigned User-ID and password (and/or token (e.g., SecurID card)).
             b. Use only approved licensed software.
             c. Use a device with virus protection software.
    16. I will never:
             a. Disclose passwords, PINs, or access codes.
             b. Use tools or techniques to break/exploit security measures.
             c. Connect unauthorized systems or devices to the Company network.
    17. I will practice good workstation security measures such as locking up diskettes when not in use, using screen
        savers with activated passwords, positioning screens away from public view.
    18. I will immediately notify the Company facility’s Facility Information Security Official (FISO), Director of
        Information Security Operations (DISO), or Facility or Corporate Client Support Services (CSS) help desk if:
             a. my password has been seen, disclosed, or otherwise compromised;
             b. media with Confidential Information stored on it has been lost or stolen;
             c. I suspect a virus infection on any system;
             d. I am aware of any activity that violates this agreement, privacy and security policies; or
             e. I am aware of any other incident that could possibly have any adverse impact on Confidential
                  Information or Company systems.

     Upon Termination
    19. I agree that my obligations under this Agreement will continue after termination of my employment, expiration
        of my contract, or my relationship ceases with the Company.
    20. Upon termination, I will immediately return any documents or media containing Confidential Information to
        the Company.
    21. I understand that I have no right to any ownership interest in any Confidential Information accessed or created
        by me during and in the scope of my relationship with the Company.

By signing this document, I acknowledge that I have read this Agreement and I agree to comply with all the terms and
conditions stated above.

 Vendor Signature                                                           Facility Name and COID      Date

 Vendor Printed Name                                                        Business Entity Name




  6/2011
                              CREDIT CARD PAYMENT AUTHORIZATION



Name as it appears on Card: _____________________________ Date: _____/____/_____



Print Name of Representative (if not the same as card holder)___________________________________



Name of Company/Vendor



I, ____________________________________ hereby give my permission for Parallon Workforce

Management Solutions to charge the cost of $250 Processing fee to my:

____________ Visa ____________ MasterCard __________ AMEX __________ Discover



CREDIT CARD NUMBER: ______________________________________________________________

EXPIRATION DATE: _______/________/________

NAME AS IT APPEARS ON CARD: ______________________________________________________

BILLING ADDRESS ON CREDIT CARD ACCOUNT: ________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Cardholder’s Signature: ______________________________________________________________

Comments: _________________________________________________________________________

____________________________________________________________________________________

                    *WE ARE NO LONGER ACCEPTING PERSONAL CHECKS*

           **PLEASE MAKE OUT ANY COMPANY CHECKS TO ALL ABOUT STAFFING**

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:16
posted:12/11/2011
language:English
pages:20