Dear Doctor,(10)
Document Sample
STEP 2
Dear Physician,
Thank you for your continued interest in the Colorado Permanente Medical Group, K.P. Prior to
completing Step 2, you should have submitted your personal CV and completed the Initial
Application attached to Step 1. Please proceed with next step in our application process. Step 2:
Please complete The Colorado Health Care Professional Credentials Application (CHCPCA),
note that pages 25 and 26 are to be completed at a later time, and the Supplemental Credentials
Application. To expedite the process, please return via e-mail. In addition, please mail or fax
your completed application to us with your original signatures.
Our Group is organized as a professional corporation and all physicians are salaried staff. Full
time board certified physicians become eligible for shareholder status, with voting rights, after
three years, if all eligibility criteria is met. However, all physicians are eligible to participate
fully in the Group’s “cash or deferred” profit-sharing plan after two years. Base salaries are
competitive, with an excellent benefit package. Full malpractice coverage is provided.
Application return information:
Primary Care Physicians: E-mail applications to: Chantal.Papez@kp.org
Specialty Physicians: E-mail applications to: Kathleeen.M.Ward@kp.org
Mailing Address:
Colorado Permanente Medical Group, P.C.
Physician Recruitment
10350 East Dakota Ave.
Denver, CO 80247
FAX: 303-344-7818
We appreciate your taking the time to complete our applications and look forward to exploring
our career opportunities with you.
Yours truly,
CPMG Recruitment
1-866-239-1677
Page 1 of 7 Revised 7/1/2007
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KAISER PERMANENTE
SUPPLEMENTAL CREDENTIALS APPLICATION
This supplemental credentials application is required in addition to the Colorado Health Care Professional Credentials
Application. All releases and information provided in the Colorado Health Care Professional Credentials Application and the
Kaiser Permanente Supplemental Credentials Application will constitute the entire credentials application.
Employment/Participation decisions are made, without regard to ethnic/national identity, sexual orientation, religion, gender,
age, physical or mental disability, type of procedure or patient in which the practitioner specializes, U.S. military veteran
status, or other status protected by applicable federal, state or local laws. Upon request, reasonable accommodation for the
credentialing application process may be provided.
Name: __________________________________________ MD DO
DDS, DMD DC
Specialty: _______________________________________ DPM AHP
PURPOSE OF APPLICATION (CHECK ALL THAT APPLY):
I wish to be considered for credentialing/recredentialing by Kaiser Permanente Colorado (KPCO).
I wish to be considered for employment by the Colorado Permanente Medical Group, P.C. (CPMG).
I wish to be considered for employment by Kaiser Foundation Health Plan, Inc of Colorado (KFHPCO).
INSTRUCTIONS:
Please complete each section of this application as needed. This form should be typed or legibly printed in black
or blue ink. Do not use “white-out” or correction tape. If you make an error draw a single line through it, write
the correct information next to it and initial the change. If there are any gaps in time between education/training,
or employment or affiliation as reported on your application, please provide information about your activities
during those times. An incomplete application will not be processed.
Section I: PREVIOUS EMPLOYER STANDING
A) Please provide the reason for leaving each of your previous employers on Schedule #1.
B) Are you eligible for re-hire with all prior employers? YesNo
(If no, please explain on Schedule #1).
Section II: PROFESSIONAL LIABILITY INSURANCE INFORMATION
In addition to the insurance information you provided on the Colorado Health Care Professional Credentials
Application, please list any other professional liability carriers within the past 10 years on Schedule #2.
Section III: CLAIM FORM
If you answered “YES” to any of the questions regarding claims on Colorado Health Care Professional
Credentials Application (Professional Liability Insurance Section), please complete Schedule #3.
Section IV: EXPLANATION FORM
Please use this form to provide any additional information regarding your application.
PLEASE SUBMIT THIS COMPLETED FORM ALONG WITH ATTACHMENTS TO:
Credentialing – CPMG Human Resources
Kaiser Permanente
10350 East Dakota Avenue
Denver, Colorado 80247-1314
FAX: (303) 344-7384
Page 2 of 7 Revised 7/1/2007
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KAISER PERMANENTE
APPLICANT RELEASE/AGREEMENT/ATTESTATION
I understand that Kaiser Permanente will rely upon the information given in this supplemental credentials application, in
conjunction with the information I provided in the Colorado Health Care Professional Credentials Application, to assess my
qualifications. Such information will be considered confidential. I further understand that reference information as well as
any other information obtained concerning my professional competence will be considered confidential, as provided by law,
and will not be subject to my review.
I agree that it is my duty and ethical responsibility as an individual practitioner and as an applicant for clinical privileges,
and/or as an employed physician of the Medical Group, to cooperate with and assist colleagues in evaluating not only my
professional qualifications, but those of my colleagues. I also agree and consent to peer review and disclosure of
information through any combined peer review process formed by Colorado Permanente Medical Group, P.C. or Kaiser
Foundation Health Plan, Inc., and another health care provider authorized to conduct peer review under Colorado Law.
If hired, appointed, granted clinical privileges, and/or approved to participate, I specifically agree to: (1) refrain from fee
splitting or other inducements relating to patient referrals; (2) refrain from delegating responsibility for diagnoses or care of
patients to any practitioner who is not qualified to undertake this responsibility or who is not adequately supervised; (3)
refrain from deceiving patients as to the identity of any practitioner providing treatment or services; (4) seek consultation
whenever appropriate, necessary or required; (5) abide by generally recognized ethical principles applicable to my
profession, including maintaining patient confidentiality; (6) provide continuous care and supervision as needed to all
patients for whom I have the responsibility; (7) accept such duties and responsibilities as shall be assigned to me by the
Colorado Permanente Medical Group and/or the Professional Staff and the Hospital; and (8) practice within the scope of my
delineated privileges in the hospital and within the scope of practice authorized by the Colorado Permanente Medical
Group, P.C., or Kaiser Foundation Health Plan, Inc. where applicable.
I understand that any material misrepresentations or misstatements in or omissions from this application or any other
employment/participation forms, whether intentional or not, shall constitute cause for automatic and immediate denial of
employment, participation, and/or clinical privileges. If participation, employment, and/or privileges have been granted
prior to the discovery of such misrepresentation, misstatement, or omission, such discovery may result in immediate
suspension or termination of such employment, participation and membership, and/or clinical privileges.
I also understand that although this form may be used for employment with CPMG, or employment with KFHPCO, and
credentialing by KPCO, the application processes are distinct. Employment by CPMG or KFHPCO does not bestow or
imply that credentialing will be approved. Also, the granting or continuation of privileges at a KPCO Contracted Hospital
or Ambulatory Surgery Center does not bestow or imply continued employment with CPMG or KFHPCO.
I further understand that my employment/participation may be contingent upon credentialing and/or privileging. I also
understand that my employment, participation and/or the granting of membership and clinical privileges is contingent upon
my furnishing information regarding my health status and demonstrating that my physical and mental health are adequate to
perform the essential duties of the clinical privileges and/or position involved.
________________________________________________________________
APPLICANT NAME (Please Print)
________________________________________________________________
APPLICANT SIGNATURE
________________________________________________________________
DATE
Page 3 of 7 Revised 7/1/2007
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KAISER PERMANENTE
SUPPLEMENTAL CREDENTIALS APPLICATION
SCHEDULE #1 – PREVIOUS EMPLOYER STANDING
(A) List reason for leaving current and all previous employment.
Name of Current Practice / Employer:
Reason for leaving:
Name of Previous Practice / Employer:
Reason for leaving:
Name of Previous Practice / Employer:
Reason for leaving:
Name of Previous Practice / Employer:
Reason for leaving:
Name of Previous Practice / Employer:
Reason for leaving:
Name of Previous Practice / Employer:
Reason for leaving:
(B) If you answered “No” to Section I (B), please list the name of the employer(s) where you are not eligible for
re-hire and give an explanation.
Name of Prior Practice / Employer:
Explanation:
Name of Prior Practice / Employer:
Explanation:
Page 4 of 7 Revised 7/1/2007
KAISER PERMANENTE
SUPPLEMENTAL CREDENTIALS APPLICATION
SCHEDULE #2 – PROFESSIONAL LIABILITY INSURANCE INFORMATION
Yours or your supervising agent.
Previous Insurance Carrier / Provider of Professional Liability Coverage:
Policy Number: Type of Coverage (check one): Claims-Made Occurrence
Per claim limit of liability: $ Aggregate amount: $
Effective Date (mm/yy): Expiration Date (mm/yy): Retroactive Date (mm/yy):
Name of Local Contact (e.g., insurance agent or broker):
Mailing Address:
Telephone Number: ( ) - Fax Number: ( ) -
Previous Insurance Carrier / Provider of Professional Liability Coverage:
Policy Number: Type of Coverage (check one): Claims-Made Occurrence
Per claim limit of liability: $ Aggregate amount: $
Effective Date (mm/yy): Expiration Date (mm/yy): Retroactive Date (mm/yy):
Name of Local Contact (e.g., insurance agent or broker):
Mailing Address:
Telephone Number: ( ) - Fax Number: ( ) -
Previous Insurance Carrier / Provider of Professional Liability Coverage:
Policy Number: Type of Coverage (check one): Claims-Made Occurrence
Per claim limit of liability: $ Aggregate amount: $
Effective Date (mm/yy): Expiration Date (mm/yy): Retroactive Date (mm/yy):
Name of Local Contact (e.g., insurance agent or broker):
Mailing Address:
Telephone Number: ( ) - Fax Number: ( ) -
Page 5 of 7 Revised 7/1/2007
KAISER PERMANENTE
SUPPLEMENTAL CREDENTIALS APPLICATION
SCHEDULE #3 – PROFESSIONAL LIABILITY CLAIMS INFORMATION FORM
If you answered "YES" to any of the questions regarding claims on the Colorado Health Care Professional Credentials
Application (Professsional Liability Insurance Section), you must complete this form, with respect to any claim, threatened claim,
settlement, or suit involving you, regardless of the outcome. COMPLETE THIS FORM FOR EACH CLAIM. Please make
copies as needed. ALL QUESTIONS MUST BE ANSWERED COMPLETELY. Please type or print.
1. Name of Patient:____________________________________________ Age: _______________ Sex: _______________
2. Relationship to patient (e.g. primary care physician, surgeon, etc.)
_________________________________________________________________________________________________
3. Allegations of claim made against you:
_________________________________________________________________________________________________
4. Date of incident / treatment:____________________ Location:_______________________________________________
5. Condition, diagnosis and care at time of incident:
_________________________________________________________________________________________________
6. Subsequent condition or health of the patient:
_________________________________________________________________________________________________
7. Insurance carrier or provider of professional liability coverage:
_________________________________________________________________________________________________
8. Other defendants in case (if any): ______________________________________________________________________
9. Status (check one)
Incident Only (no claim made as of yet) Claim or Notice of Claim Filed Suit Filed
Date of Claim: ______________________ Open Closed* Date Closed:_____________________
Dismissed or Dropped*: _______________ With Prejudice: ___________ Without Prejudice: ________________
Settled*: Date:____/____/____ Total Amount: $_____________ Amount paid on your behalf: $______________
Judgment: Date:____/____/____ Total Amount: $_____________ Amount paid on your behalf: $______________
* Please attach final letter/legal documentation for claims that were Closed, Dismissed, Dropped or Settled.
10. Additional Comments:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
I hereby declare that the above information is, to the best of my knowledge and belief, complete and accurate.
Signature of
Applicant: ________________________________________________________Date:___________________________________
Print Name: _______________________________________________________
Page 6 of 7 Revised 7/1/2007
KAISER PERMANENTE
SUPPLEMENTAL CREDENTIALS APPLICATION
Section IV - EXPLANATION FORM
Please make as many copies of this page as needed to fully respond to each question. For each response,
please be sure to provide the page and section number from the Colorado Health Care Professional
Credentials Application.
Page # Section
#
Page 7 of 7
Revised 7/1/2007
