NOEH Pre-application for Medical Staff Privileges

Pre-Application

Thank you for your interest in becoming a member of the Medical Staff at New Orleans East Hospital. Please be aware that this form must be completed in full prior to submission. Incomplete Pre-Applications will not be accepted.

Name of provider requesting medical staff privileges*

First Name

Last Name

Provider's preferred phone #*

Provider's cell phone*

Provider's fax #

Provider's email*

Provider's address*

Address Line 1

Address Line 2

City

State

ZIP Code

Office address if different from above

Address Line 1

Address Line 2

City

State

ZIP Code

Provider's office phone if different from above

Provider's office email if different from above

Office contact name (if different from applicant, who may we contact about this application?)

Office contact email

Corporate status - by whom will this provider be employed? (select option)*

Current LA State license #

Degree (select an option)*

NPI #

Is the provider Board-certified?

If yes, please specify Board(s):

Does this provider have a university affiliation?

If yes, please provide name(s) of university(ies):

In chronological order, please list ALL hospitals at which provider has held clinical privileges during the last five (5) years. (if none, indicate N/A)*

Has any past adverse licensure action against the provider ever been taken by any state or federal licensing board?*

Has the provider had any felony convictions?*

Has the provider had any convictions of Medicare, Medicaid, or insurance fraud or exclusion from such programs?*

Has the provider had any conviction of felony or misdemeanor related to professional practice, reimbursement, or controlled substance violations? *

Has the provider’s medical staff privileges or appointments ever been modified, denied, revoked or terminated for reasons related to professional competency or conduct or during an investigation into competency or conduct?*

Does the provider have professional liability insurance coverage?*

Type of privilege provider is requesting (select an option)*

In which Service Line/Specialty is this provider seeking privileges?*

Is this provider trained in Pediatrics?

List specialty(ies) in which this provider is trained (if more than one, separate by "," and list maximum three)*

Cross-covering physician/provider full name

First Name

Last Name

Cross-covering physician/provider phone number

Cross-covering physician/provider email

Provider's anticipated start date --- Please note --- Processing an application for medical staff privileges can take an average of 90-120 days. Please keep this in mind especially if the provider is pending issuance of a Louisiana medical license. The anticipated start date is not guaranteed and may be adjusted to accommodate processing and/or Committee and Board approvals.*

If offer letter and/or employment agreement been executed with NOEH/LSU/Tulane, please upload a copy.

No File Chosen

File uploads may not work on some mobile devices.

If being employed by NOEH/LSU/Tulane, please provide the Service Line Chief's and/or HR recruiter's name with whom this provider is coordinating employment. If not being employed by NOEH/LSU/Tulane, indicate - ONLY SEEKING MEDICAL STAFF PRIVILEGES, and provide practice name.

Why would this provider like to become a member of NOEH's medical staff?

Upload CV in MM/YYYY format (Word or PDF)*

No File Chosen

File uploads may not work on some mobile devices.

CV must include all dates in the MM/YYYY format

Name of person filling out this form if other than provider*

First Name

Last Name

Email of person filling out this form if other than provider

Any additional information/notes

Are you interested in requesting moderate and/or deep sedation privileges?*

Please note - processing an application for medical staff privileges can take an average of 90-120 days.

Should the provider be eligible for the Initial Application once the Pre-Application has been approved and all materials have been submitted to NOEH's Medical Staff Office to process, verification and review of the application will include at least the following:

- Authentication of all information provided on the Initial Application form.

- Evaluation of at least three (3) references from physicians who are familiar with the provider’s current work and competence. The provider will provide the references and should follow up with them to be sure that they have responded.

- Review of information from the provider’s malpractice insurance carrier(s) regarding claims, suits, and settlements.

- Evaluation of letters of reference from department chiefs and/or management from other hospitals and health care facilities with which the provider is now or have been affiliated.

- A query to the National Practitioner Data Bank, as required by law.

- A query regarding Medicare, Medicaid, and insurance fraud and abuse or loss of participation in Medicare or Medicaid is also required by the Board of Directors.

- An in-depth interview may be conducted by the chairperson of the department in which the provider requests privileges and possibly with the Credentials Committee including, but not limited to, the specific hospital privileges requested, and inquiries bearing on individual character, competence, experience, and judgment. (This review may include a request for a review of hospital charts from other hospitals where provider has practiced.)

Note:

- No applicant is automatically entitled to staff membership or the right to exercise any clinical privileges solely on the basis of his or her license to practice medicine in Louisiana or any other state, membership in any professional organization, certification by any clinical examining board, or clinical privileges or staff membership at another hospital. (La. Revised Statute 40:2114)

- Processing an application for medical staff privileges can take an average of 90-120 days. Please keep this in mind especially if the provider is pending issuance of a Louisiana medical license. The anticipated start date is by no means guaranteed and may be adjusted to accommodate processing and/or Committee and Board approvals.

- Any misrepresentation, misstatement, or omission during the application process, whether intentional or not, is cause for the immediate cessation of the processing of this application and no further processing shall occur. Upon subsequent discovery of such misrepresentation, misstatement, or omission, the entity to which the provider is applying may deem any relationship they have with the provider to be automatically relinquished, including but not limited to medical staff appointment, clinical privileges, participating provider status or contracts. In either situation, there shall be no entitlement to any hearing or appeal rights that are contained in the entities bylaws, policies, or contracts.

By checking this box, the provider attests to reading and understanding all conditions that are required to apply and join NOEH's Medical Staff:*

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If you are you applying to multiple LCMC Health facilities, please be advised that you must complete a pre-application for each facility at their independent website.