Touro - Prospective Physician Form

Pre-Application

Thank you for your interest in joining Touro's Medical Staff. Please complete this form to receive an application packet.

To be eligible to join our medical staff:

You must have a current unrestricted license or application pending to practice medicine, dentistry, osteopathy, or podiatric medicine in Louisiana and a current Federal Drug Enforcement Agency (DEA) number (if required by your specialty). If you do not currently have a Louisiana License, you must hold an unrestricted license in another state and have an application pending with the Louisiana State Board of Medical Examiners.

You must have no record of past adverse licensure action by any state or federal licensing board.

You must demonstrate you are board-certified, or that you have satisfactorily completed an accredited postgraduate residency training program approved by the American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) or American College of Graduate Medical Examiners (ACGME) in the specialty in which you will seek clinical privileges. You must be eligible to take the certifying examination in that specialty.

Medical Staff applications will be sent only to providers of high moral character. The following precludes application.

A. Felony convictions of any type.

B. Conviction of Medicare or Medicaid or insurance fraud or exclusion from such programs.

C. Conviction of a felony or misdemeanor related to professional practice, reimbursement, or controlled substance violations.

You must have no record of denial, revocation or termination of appointment or clinical privileges by any hospital for reasons related to professional competence or conduct.

In addition to the qualifications set forth above, appointment to and maintenance of Medical Staff membership shall be subject to and conditioned upon such other qualifications and requirements as may be expressed or implied elsewhere in Medical Staff Bylaws and Credentials Policy and Procedure Manual.

Name*

First Name

Middle Name

Last Name

Please specify your degree*

Cell Phone**

Email*

Home Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Office Information

Cell Phone*

Office Phone*

Office Fax Number*

Office Email*

Office/Practice Name:*

Office Address*

Address Line 1

City

State

ZIP Code

Office Contact Name*

Office Contact's Phone

Office Contact's Email*

Additional Information

Email address to receive application information*

Date Of Birth (MM/DD/YYYY)*

Current LA State License Number*

National Practitioner Identification (NPI) number:*

Are you board-certified in any specialty?*

Yes No New Graduate

If yes, please specify:

Are you with a university?*

Yes No

If yes, please specify:

Please list your current primary facility:*

Types of Privileges you are requesting:

ACTIVE STAFF: Regularly admit, or are otherwise regularly involved in the care of patients in this facility (a minimum of eleven [11] patient contacts per year of appointment) or are regularly involved in Medical Staff functions, as determined by the Medical Staff.Accept on-call coverage for emergency care services within his/her Medical Staff Division as specified by the requirements of the assigned Medical Staff Division.

COURTESY STAFF: Admitting privileges and performance of procedures are restricted to a maximum of eleven [11] patient contacts per year of appointment

.AFFILIATE STAFF: Perform outpatient preadmission and history and physical exam, order noninvasive outpatient diagnostic tests and services, visit patients in the hospital, view only medical record privileges, and observe diagnostic or surgical procedures with the approval of the attending physician or surgeon. Cross-covering physician not required as no clinical privileges are granted.

Types of Privileges you are requesting*

Please list your specialty/specialties:*

Cross Covering Contact's Name:

You are required to have a Cross Covering Physician. This physician must be a member of Touro’s Medical Staff or currently applying for Medical Staff appointment. Your cross covering physician should also have the same type of privileges you are requesting.

Cross Covering Contact's Name*

Cross Covering Physician Phone Number*

Cross Covering Physician Email*

Why would you like to become a member of Touro's medical staff?

For example, to provide coverage for a physician on Touro’s active staff, to join a group associated with Touro Infirmary, or relocating to the New Orleans/Uptown area.

Why would you like to become a member of Touro's medical staff?*

Should you be eligible for Application once the pre-application has been approved and all materials have been returned to Touro’s medical staff office to process, an investigation and review of your Application will include at least the following:

Verification of all information provided on the Application form.
Proof of all required immunizations or a completed LCMC granted exemption form.
Evaluation of at least three references from physicians who are familiar with your current work and competence. You will provide the references and should follow up with them to be sure that they have responded.
Review of information from your malpractice insurance carrier(s) regarding claims, suits, and settlements for the past five years.
Evaluation of letters of reference from department chiefs and/or management from other hospitals and health care facilities with which you are 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 conducted by the chairperson of the department in which you request privileges and possibly with the Credentials Committee including, but not limited to, the specific hospital privileges requested, and inquiries bearing on your individual character, competence, experience, and judgment. (This review may include a request for a review of your hospital charts from other hospitals where you have 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)

By checking this box, I have read and understand all conditions that are required to apply and join Touro’s Medical Staff.*

Check box here

Name

First Name

Last Name

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.