Pre-Application for Staff Privileges Form

Anticipated Start Date: *

Specialty: *

'Other' specialty?

Provider: *
(First, Middle-initial, Last)

Degree: *
(MD, DO, DDS, etc.)

Date of Birth: *

Social Security #: *

NPI #: *

Office Name/Address: *

Office Phone: *

Fax:

E-mail: *

Pager:

Administrative Contact:

Contact E-mail:

Contact Phone:

Have you previously worked at CHCO in any capacity?: *

Yes
No

Are you Board Certified: *

Yes
No
N/A (add explanation below)

Are you within 5 years of training completion?

YesNo

Please explain
(Foreign Medical Graduate, etc.)

Select your primary location: *

Anschutz/Network of Care
Colorado Springs

Select the other locations where you will be practicing (Additional privileging documents may be required): *

'Other' Practice Locations: *

Are you employed by: *

Children's Hospital Colorado
University of Colorado School of Medicine (Faculty)
Community Practice
Previously employed by Children's Hospital Colorado (add comments)

When were you previously employed by Children's Hospital Colorado: *

What is your intent/purpose for obtaining privileges at Children's Hospital Colorado? *

Consent to Initiate Credentialing: *

Yes
No

Will you be requesting any of the following privileges?

Laser
Sedation

Are you participating in the Children’s Hospital Colorado Locums, PCN (Pediatric Care Network) or PedsConnect programs?

Locums
PCN
PedsConnect

Staff Category: *

Based on your anticipated level of involvement at Children's Hospital Colorado, please select the category you will be requesting after your provisional period (6 months) is completed.

Attending/Admitting

This category is intended for licensed medical physicians, osteopathic physicians and dentists who desire to be active in CHCO programs and have clinical activity at CHCO. Provider must admit, treat, provide therapeutic or diagnostic services for, or consult on (a) at least five (5) patients a year, or (b) an average of ten (10) patients over two (2) years, or the provider must be approved for low volume provider status by hisIher Department Chair.

Providers in this Attending/Admitting category cover Emergency Department call or take call for a practice that actively attends on patients at CHCO. Providers in this category will be subject to a focused professional practice evaluation upon initial Medical Staff appointment and ongoing professional practice evaluation thereafter as delineated by their department-specific criteria. Practitioner will maintain certification appropriate with his/her training/specialty (i.e. board certification) when applicable.

Providers in this Attending/Admitting category shall be eligible to vote and to hold office on the Medical Board. They shall be expected to actively participate in activities as outlined in these Bylaws and Medical Staff rules, regulations, Policies and Procedures, and in division/department rules and policies, and they shall be expected to serve on committees of the Hospital and Medical Staff, if requested. Failure to meet these requirements may constitute grounds for changing the Medical Staff category of the provider as determined by the Medical Executive Committee.

General Membership

This category is intended to encompass two groups: 1) licensed medical or osteopathic physicians, dentists, and Ph.D. level providers who desire to be active in CHCO programs and participate in educational, teaching, research, administrative and/or supportive activities ("General Physician Membership"); and 2) licensed independent practitioners (including Nurse Practitioners, Physician Assistants, Child Health Associates, and other licensed health care professionals) who desire to be active in CHCO programs and participate in educational, teaching, research, administrative and/or supportive activities ("General Non-Physician Membership"). Physician and Non-Physician Medical Staff in the General Membership category may visit patients, write progress notes, and may have access to the CHCO electronic medical record. Following initial credentialing and appointment, both groups shall provide biennially to the Medical Staff Office current information on licensure, DEA registration, malpractice insurance and health status, as applicable, and shall maintain certification appropriate with his/her training/specialty (i.e. board certification), as applicable. Medical Staff in the General Membership category shall not have independent admitting or treating privileges nor the authority to provide or direct patient care. Non-Physician members in this category shall not be eligible to vote or to hold office on the Medical Board. Physician Medical Staff Members in this category shall be eligible to vote and to hold office on the Medical Board.

Associated Scientific Medical Staff

The Associated Scientific Medical Staff shall consist of providers who hold a doctorate degree and/or who, by virtue of their specialized scientific training, can (a) provide essential supportive services, (b) provide supportive and independent clinical services within the limits defined by their training, experience, licensure and all relevant hospital and departmental policies and standards, (c) conduct research appropriate to their training in accordance with governing regulations, and (d) carry out certain responsibilities of teaching where appropriate. Providers in this category shall be expected to actively participate in activities as outlined in the Medical Staff rules, regulations, Policies and Procedures, and in division/department rules and policies and be expected to serve on committees of the Hospital and Medical Staff, if requested. Failure to meet these requirements may constitute grounds for changing the Medical Staff category of the Member as determined by the M e d i c a l Executive Committee. Providers in this category will be subject to a focused professional practice evaluation upon initial Medical Staff appointment, and ongoing professional practice evaluation thereafter as delineated by departmental-specific criteria. Associated Scientific Medical Staff shall maintain licensing and certification appropriate with his/her training/specialty (i.e. board certification) when applicable or required by law.

Associated Scientific Medical Staff Members shall be eligible to vote and to hold office on the Medical Board.

Adjunct Medical Staff

The Adjunct Medical Staff shall consist of providers who do not fall within the categories of Attending/ Admitting Members or General Membership Members and who are considered licensed independent practitioners, including but not limited to Nurse Practitioners, Certified Nurse Midwives, Certified Registered Nurse Anesthetists, Anesthesiologist Assistants, Physicians Assistants, Child Health Associates, licensed professional counselors, Independent Licensed Clinical Social Workers, and other licensed health care professionals who provide professional services at CHCO and who exercise independent judgment within the areas of his/her professional competence and the limits established by the Board, the Medical Staff and applicable law. Adjunct Medical Staff Members may provide supportive and clinical services in accordance with Article V Section 7 and within the limits defined by their training, experience, licensure, certification and all relevant Medical Staff rules, regulations, Policies and Procedures, and Hospital and division I departmental policies and rules.

An Adjunct Medical Staff Member must have at least 5 patient contacts annually and will be subject to focused professional practice evaluation upon initial appointment and ongoing professional practice review thereafter. Adjunct Medical Staff Members shall maintain certification appropriate wi t h hi s /her training/specialty ( i.e. board certification) when applicable.

Adjunct Medical Staff Members shall not be eligible to vote or hold office on the Medical Board. They shall be expected to actively participate in activities as outlined in the Medical Staff rules, regulations, Policies and Procedures, and in division/department rules and policies and be expected to serve on committees of the Hospital and Medical Staff if requested. Failure to meet these requirements may constitute grounds for changing the Medical Staff category of the member as determined by the Medical Executive Committee.

Allied Health Staff

Practitioners including, Surgical Assistants, Physical Therapists, Occupational Therapists, Speech and Language Pathologists, Acupuncturists, Audiologists, and those Licensed Clinical Social Workers and Licensed Professional Counselors that are not functioning in an Adjunct staff role and others, may be afforded Allied Health privileges

Application Fees:

Admitting/Attending or Associate Staff: $425
General Membership/Adjunct/APN/APNRX: $250
PedsConnect Only Providers: $75
PCN Providers: $0
Allied Health Providers: $50

Payment can be made via the web at https://chcomedstaff-pp-prtl.spectrumretailnet.com/PP?PAGE=GUESTPAY. Your application will be sent once this information is received. If you have any questions, please contact Medical Staff Services at 720-777-6652.

VERIFICATION OF CREDENTIALS AND PRIVILEGE APPROVAL WILL TAKE A MINIMUM OF 120 DAYS (4 MONTHS) AFTER SUBMISSION OF A COMPLETE APPLICATION. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED WITHIN THIS TIME FRAME. TEMPORARY PRIVILEGES WILL NOT BE GRANTED UNLESS A JUSTIFIABLE, EMERGENT PATIENT CARE NEED IS PETITIONED BY THE DEPARTMENT CHAIR AND REVIEWED/APPROVED BY THE CHIEF MEDICAL OFFICER. SUBMISSION OF THIS PREAPPLICATION IS CONSENT TO ALLOW CHILDREN’S HOSPITAL COLORADO TO BEGIN THE CREDENTIALING PROCESS TO DETERMINE IF THRESHOLD CRITERIA IS MET. FOLLOWING THIS A FULL APPLICATION WILL BE SENT.

NO COLORADO LICENSE = NO PRIVILEGES

Pre-Application for Medical Staff Privileges