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First Name*

Last Name*

Email Address*

Date of Birth*

Month Day Year

1. Demographics (PLEASE CHANGE ANY OUTDATED DATA)

Office Address

Office City

Office Postal Code

Office Back Line

Residence Address*

Residence City*

Residence Postal Code*

Home Phone*

Preferred telephone number for CMH administration purposes*

Pager

2. Privilege Category Requested (PLEASE COMPLETE)

Privilege Category*

Program*

Sub Specialty

Do you want to change your privileges from the previous year?

Yes

No

If so what category?

3. Professional Information

OHIP Billing #

Please indicate that you have completed CMH LMS Modules*

Yes

Canadian Medical Protective Association No.

Canadian Medical Protective Association (Please attach copy of current CMPA coverage)

Other Malpractice Protection (Please attach copy of Proof of Malpractice Protection)

CPSO Active Membership (Please attach copy of current CPSO Membership Card)

Please attach proof of your N95 Fit Test *

Midwives/Dentists/Other Professionals - Professional Registration # (Please attach copy of current College Registration

Please include proof of: PALS, NRP, CPR and ACLS or ACES certification, IF APPLICABLE
- ER Physicians are required to maintain ACLS and PALS certification
- Pediatricians shall maintain current PALS and NRP certification -
- Internists taking Internal Medicine call shall maintain current ACLS certification
- Hospitalists are required to maintain ACLS certification

Please attach copy of current PALS certification

Please attach copy of current NRP certification

Please attach copy of current CPR certification

Please attach copy of current ACLS certification

Please attach copy of current ACES certification

Methadone License

Do you prescribe Suboxone

Yes

No

*For Family Physicians Only* Do you wish to be MRP for your patients in the Nursery?

Yes

No

4. COMPLETE ONLY IF REQUESTING COURTESY PRIVILEGES

Medical Staff requesting Courtesy privileges must hold Active privileges at another hospital.

a) Please list activities requested

b) Do you want admitting privileges

Yes

No

5. Professional Issues

The following information will be kept in strictly confidential.

Answering "Yes" to any questions in (i) - (vii) does not necessarily mean that you will be denied privileges. If any are "Yes", please provide an explanation below.

(i) Have you been the subject of a formal complaint to your licensing body (CPSO, Dental, Midwifery, College of Nurses), within the past year?

Yes

No

(ii) Are you presently being investigated by the CPSO, Dental Board, College of Midwives, or College of Nurses?

Yes

No

(iii) Have you been treated for any drug or alcohol related problems, within the past year?

Yes

No

(iv) Have you experienced any health problems that would affect your ability to carry out assigned privileges or that may have an impact on patient care? If yes, please append particulars and also consult with your Chief of Service)

Yes

No

(v) Have you been a defendant in any civil or criminal law suit alleging negligence, incompetence, assault, battery, sexual misconduct or that arose in any way from your professional practice or that is in anyway relevant to the practice of medicine, dentistry, midwifery, or nursing in the past year?

Yes

No

(vi) Have you had any criminal and/or civil actions brought against you in the past year or pending?

Yes

No

(vii) Do you maintain privileges at any other hospital(s)?

Yes

No

If Yes: Hospital (list)

If Yes: Privilege Category

If you answered "Yes" to 5 (vii), please complete the following:

(viii) Have your hospital privileges been reduced, suspended or terminated for any reason within the past year?

Yes

No

Not Applicable

(ix) Have you voluntarily relinquished part or all of your hospital privileges within the past year?

Yes

No

Not Applicable

(x) Have you been the subject of patient concerns that have been brought to the MAC within the past year?

Yes

No

Not Applicable

If "Yes" to any (i)-(x) please provide or attach particulars:

(i) - (x) Particulars

6 Restricted Licensing Update

Please complete only if you hold a restricted license to practice.

(i) Expiry of current license

(ii) Restrictions - please provide an update on the status of your independent practice license (e.g. when you will be writing your qualifying examinations, work permit status, etc.)

7. Continuing Medical Education (MUST BE COMPLETED)

As approved by the Professional Staff, the CME requirement is 20 hard hours (lectures and seminars) and 20 self-directed hours. Please include a print out of your continuing education during the past 12 months and any peer review/evaluations you have had in the past 12 months.

By checking this box I certify that I have completed the CME requirement of 20 hard hours (lectures and seminars) and 20 self-directed hours in the past 12 months

Yes

CME transcript

8. Hospital Coverage

Twenty-four hour coverage of hospital patients, including those in the ER, is a requirement of Professional Staff responsibilities. The physician must provide an acceptable method to respond to hospital calls.

a) Who covers your hospital patients when you are not available? (List individuals or group)*

b) If you are practicing obstetrics, who covers your patients when you are not available? (List individuals or group)

9. Medical Directives

There are Medical Directives approved for use at the Cambridge Memorial Hospital.

Please ensure all of your medical directives are reviewed and submitted.

I hereby confirm that in signing below, I agree to the delegation and implementation of the Medical Directives and Delegated Acts used within the Cambridge Memorial Hospital.

All Medical Directives and Delegated Acts are available for your review on the Hospital Intranet at: cmhnet/resources/clinical_learning/medical_directives.htm

10. Statement of confirmation, undertaking, acknowledgement and agreement

i. certify that the information contained in this re-application is current and correct;

ii. agree that if my application for reappointment to the Medical Staff is approved, to abide by the Public Hospitals Act of Ontario, to conform to the CMH Bylaws, Medical and Professional Staff Rules and Regulations, Cambridge Memorial Hospital By-laws, Accessibility for Ontarians with Disabilities 2005 Customer Service Regulation 429-07, Integrated Accessibility Standards Regulation 191-11 and Hospital policies and procedures applicable to the Medical and Professional Staff, the Regulated Health Professional Act of Ontario and to the professional code of conduct associated with my profession;

iii. further agree to conform to and to be bound by any amendments or additions that may from time to time be made to the above;

iv. am aware of the scope of my privilege package and agree only to perform those procedures for which I have been granted;

v. agree to the delegation and implementation of the Medical Directives and Delegated Acts used at Cambridge Memorial Hospital and as posted on the CMH website. (http://cmhnet/resources/clinical learning/medical directives.htm)

vi. acknowledge that my failure to comply with the applicable legislation, the By-Laws, the rules and Regulations and the Policies will constitute a breach of my obligations to the Cambridge Memorial Hospital and CMH may, upon consideration of the individual circumstances, remove my access to any and all Cambridge Memorial Hospital resources or take such actions as are reasonable and in accordance with the Public Hospitals Act, the By-Laws, Rules and Regulations and Policies;

vii. acknowledge that my failure to comply with my undertaking as set out in #2 above, may result in my privileges being restricted suspended or revoked or in my being denied reappointment. I understand that any such actions taken by the Cambridge Memorial Hospital will be taken in accordance with the Public Hospitals Act, the By-Laws, Rules and Regulations and Policies;

viii. understand the requirements for accepting clinical, academic and administrative responsibilities as requested by the Board of Directors of Cambridge Memorial Hospital following consultation with the Medical Advisory Committee, Chief of Staff, Chief of Department and Chief Executive Officer;

ix. agree that if reappointed to the Medical / Professional Staff of the Hospital, I will abide by Cambridge Memorial Hospital's Policies related to the confidentiality of patient information and confidentiality of corporate matters. I agree that I will not make any statements on behalf of Cambridge Memorial Hospital without the express authority of the Chief Executive Officer or his/her delegate;

x. agree that if I am reappointed to the Medical / Professional Staff of the Hospital, I will use my best efforts to provide the Cambridge Memorial Hospital with three (3) months written notice of my intention to resign. I acknowledge that my failure to provide this notice may result in the Chief of my Department notifying the College that I have failed to comply with the By-Laws and notation of the breach will be noted in my file. I understand that I may be exempted from this notice requirement if my Chief of Department believes, after consideration of the Medical Human Resources Plan, that the notice is not required or believes that there are other reasonable or compassionate grounds for granting an exemption from the requirement to provide notice;

xi. fully understand that any significant misstatements in, or omissions from, this application may constitute cause for refusal of reappointment.

Medical/Professional Staff Name*

Date*

By submitting this reappointment application, I certify that the information provided is correct and true to the best of my knowledge and I agree to submit all supporting documentation within 48 hours if my application is selected for a random audit by the Chief of Staff Office.

2023 Credentialing For Reappointment