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Forms

Annual Health Assessment  Revised April 15, 2011
To be completed by your personal physician and submitted to the Medical Staff Office (MSO) every year. RGH MDS does not require that your physician complete a physical, but complete this form attesting to your physical and mental ability. It is up to your physician to decide if he/she will complete the form without a physical. RGH MSO will also accept the Employee Health Service (EHS) form for those who are employed by RGHS.

Authorization & Release Form
This is necessary as part of the appointment and reappointment process. Sign, date and return to the Medical Staff Office when requested.

Infection Control Manual
Infection Control Certification is required every four years by New York State to maintain your state licensure. Review this manual and complete the Infection Control Test when requested by the Medical Staff Office.

Infection Control Test
When you have reviewed the manual, please complete this test, sign, date and return to the Medical Staff Office. If you pass the test, a certificate will be sent to you at your primary office address location within one week. The Medical Staff Office will retain a copy. Be sure to send a copy of your certificate to any other healthcare facilities where you may be a member.

Initial Health Assessment  Revised July 12, 2011
Required for all new applicants to the RGH Medical & Dental Staff. Return to the Medical Staff Office.

Medicare Release & Assignment Form
Required by Medicaid - The patients signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim.

The patient or authorized representative must sign and enter either a 6-digit date. (MM/DD/YY, 8-digit date (MM/DD/YYYY), or an alphanumeric date (January 1, 1998) unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file in accordance with Medicare Carriers Manual (MCM) 3047.1-3047.3. If the patient is physically or mentally unable to sign, a representative specified in MCM 3008 may sign on the patient’s behalf. In this event, the statement’s signature line must indicate the patient’s name followed by "by" the representative’s name, address relationship to the patient and the reason the patient cannot sign. The Authorization is effective indefinitely, unless the patient or the patient’s representative revokes this arrangement.

Signature by Mark (X). When the illiterate or physically handicapped enrollee signs by mark, a witness must enter his/her name and address next to the mark.

Moderate Sedation Test  Added August 10, 2011
To perform Moderate Sedation you must provide this test along with copies of certification in ACLS, BLS or Airway Management Skills. If you plan on performing Pediatric Moderate Sedation on children 12 years and under you must also provide PALS documentation.

New Applicant Attestation
To be signed and dated by all new applicants to the RGH MDS. Return to the Medical Staff Office

NP Practice Agreement
Required for all Nurse Practitioners working at RGH licensed facilities. This must be updated by you when there are any changes. A copy must be sent to the Medical Staff Office.

NP Form 4 - Verification of Experience  Updated April 26, 2013 

NP Quarterly Review  Revised January 9, 2013
Per New York State, Nurse Practitioners are required to be reviewed by their collaborating physician on a quarterly basis.  A copy of this form, signed and dated by the collaborating physician, must be submitted to the Medical Staff Office on a quarterly basis.      

NYS Nurse Practitioner Requirements for Protocol Text  New August 5, 2010
All Nurse Practitioners areo required to identify a protocol text, from the approved list, as your official practice protocol which must reflect the specialty area of practice as identified on your State Education Department issued nurse practitioner certificate. The approved protocol texts include provisions for case management, diagnosis and treatment of pathology in the specialty area. Additional protocols or textbooks which may be appropriate to the practice and/or employment setting may be used but need not be reflected in the collaborative agreement.

Questions about collaborative agreements and practice protocols may be referred to the State Board for Nursing by e-mailing nursebd@mail.nysed.gov, calling 518-474-3817 ext. 120 or by faxing 518-474-3706. 

Procedure Change Form from Direct to General Supervision for NPs and PAs 
Use form to request change in privileges from direct to general supervision for nurse practitioners and physician assistants.

Reappointment Questionnaire
Must be completed by each RGH Medical & Dental Staff Member at time of reappointment. Send a completed copy to the Medical Staff Office.

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