Butte Community Health Center

Come live, work, and play in the heart of the
Rocky Mountains all year round.

                            Community Health Center
                                   445 Centennial,
                                  Butte, MT 59701

Credentialing Application

Instructions:

1. Information must be typed or printed	5. Please return the following with your application:
2. All questions must be answered and signed where	a. Copy of current Montana License
necessary	b. Copy of Narcotic Registration (DEA)
3. If more space is needed, please attach additional sheets and reference the questions being answered.	c. Principles of Practice (Completed and signed)
4. If there is a break in the continuity of your medical	d. Copy of Board Certification (if applicable)
education, internship, residency, hospital affiliations,	e. Copy of Hepatitis-B Vaccination or Waiver
medical practice, etc., please explain.	f. Copy of most recent Tuberculosis PPD Test

Identifying Information

Last Name___________________________ First Name________________________________ Middle Initial____ S.S. #_______________

Current Employer/Professional Group Name and Address_______________________________________________________________

City_________________________________ State_____________________________________ Zip__________________________________

Tel. #________________________________Fax #______________________________________ Email________________________________

Home Address___________________________________________________________________Tel. #________________________________

City_________________________________State_______________________________________Zip__________________________________

Date of Birth__________________________ Place of Birth________________________________Citizenship____________________________

Medical Licensure Certification

____________________________________________________________________________________________________________________________________________________________
Montana License Number Issue Date Expires

____________________________________________________________________________________________________________________________________________________________
Controlled Substance Registration Certification Number (Montana) Issue Date Expires

____________________________________________________________________________________________________________________________________________________________
DEA Number Issue Date Expires

Resume Must Include:

□   Other State Medical Licenses – Past and Present:          □ Residency(ies)
□ Premedical Education                                                        □ Training, Fellowships, Preceptor ships, Postgraduate Education
□ Medical Education                                                             □ Hospital and University Affiliations
□ Other Professional Education                                           □ Previous Medical Practice
□ Internship                                                                          □ Certification
□ Professional Societies, Awarded Fellowships (ACS, ACP, etc.)

Professional Peer References

List three professional references familiar with the applicant’s qualifications during the three years immediately preceding this application. One professional reference must be from the Chief of the department or service where the applicant last furnished professional services.

1.__________________________________________________________________________________________________________________________________________________________
Name Professional Relationship

____________________________________________________________________________________________________________________________________________________________
Address City State Zip

2.__________________________________________________________________________________________________________________________________________________________
Name Professional Relationship

____________________________________________________________________________________________________________________________________________________________
Address City State Zip

3.__________________________________________________________________________________________________________________________________________________________
Name Professional Relationship

____________________________________________________________________________________________________________________________________________________________
Address City State Zip

Professional Liability: (If previously held/covered)

____________________________________________________________________________________________________________________________________________________________
Insurance Carrier Amount of Coverage

____________________________________________________________________________________________________________________________________________________________
Policy # Agent Expiration Date

Have any professional liability law suits been filed against you during the past ten years
(including those closed)?................................................................................................................................. □ Yes □ No

Are there any now still pending? ……………………………………………………………………………...……□ Yes □ No

Has any judgment or settlement ever been made against you in any professional liability cases? …….........□ Yes □ No

Have you ever been denied professional insurance, or has your policy ever been cancelled?.....................□ Yes □ No

If yes to any of the above, please explain on separate sheet.

Professional Sanctions

Has your license to practice medicine in any jurisdiction ever been limited, suspended or revoked?............ □ Yes □ No

Have you ever been refused membership on a hospital medical staff?......................................................... □ Yes □ No

Has your request for any specific clinical privileges ever been denied or granted with stated limitations?.. □ Yes □ No

Have your privileges at any hospital ever been suspended, diminished, revoked, or not renewed?.............□ Yes □ No

Has your narcotics registration ever been suspended or revoked?................................................................□ Yes □ No

Have you ever been denied membership or renewal thereof or been subject to disciplinary
Action (other than discipline for failure to complete medical records) in any medical organization
Or health insurance plan?................................................................................................................................ □ Yes □ No

Have you ever received a criminal conviction other than minor traffic violations?.......................................... □ Yes □ No

Have you been sanctioned by either the Medicare or Medicaid program?...................................................... □ Yes □ No

If yes to any of the above, please explain on separate sheet.

Health Status

Have you had an illness or physical disability that impairs, or could impair, your ability
To practice your medical specialty?................................................................................................................. □ Yes □ No

If yes, please explain on separate sheet.

By applying for clinical privileges, I hereby signify my willingness to appear for interviews in regard to my application, and authorize the Community Health Center, its medical staff and their representatives to consult with members of management and members of medical staffs of other hospitals or institutions with which I have been associated and with others, including past and present malpractice insurance carriers, who may have information bearing on my professional competence, character, and ethical qualifications.

I hereby further consent to inspection by the Community Health Center, its medical staff and its representatives of all records and documents, including medical and credential records at other hospitals, which may be material to an evaluation of my qualifications for staff membership.

I hereby release from liability all representatives of the Community Health Center and its medical staff, in their individual and collective capacities, for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and I hereby release from any liability any and all individuals and organizations who provide information to the Community Health Center or to members of its medical staff in good faith and without malice concerning my professional competence, ethics. character, and other qualifications for staff appointment and clinical privileges.

I hereby consent to the release of information by other hospitals, other medical associations, and other authorized persons, on request, regarding any information the Community Health Center may have concerning me as long as such release of information is done in good faith and without malice, and I hereby release from liability the Community Health Center from so doing.

I understand and agree that I, as an applicant for clinical privileges, have the burden of producing adequate information for the proper evaluation of my professional competence, character, ethics, and other qualifications and for the resolution of any doubts about such qualifications.

By accepting appointment and/or reappointment to the medical staff at the Community Health Center, I hereby acknowledge and represent that I have read and am familiar with the policies, rules and regulations of the Community Health Center, as well as the principles, standards and ethics of the national, state and local associations and state law and regulations that apply to and govern my specialty and/or profession, which are the “Governing Standards.” I further agree to abide by the “Governing Standards” as may be enacted from time to time.

In addition, I agree to notify the Community Health Center of any circumstances that would change my status in licensure, DEA, Medicare participation, liability insurance coverage or Board certification status or hospital privileges,

I understand and agree that any significant misstatements in or omissions from this application shall constitute cause for denial of appointment or cause for summary dismissal from the medical staff with no right of appeal. All information submitted by me in this application is true to the best of my knowledge and belief.

I further authorize a photo static copy of the requests, authorizations and releases to this application to serve as the original.

________________________________________________________________________________________________________________________________________________________
Signature of Applicant Date

____________________________________________________________________________________________________________________________________________________________
Print Name

____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________

Providers Name__________________________________________Date_____________________________________

Circle One:

Department: Medical

Site: Butte Dillon Sheridan

Age _____ 0 – 21 _____ 16 + _____ All ages ____________ If different age bracket please list.

PRINCIPALS OF PRACTICE
Privileges at the CHC Sites

The Principles of Practice (POP) is a written checklist and description of the scope of practice, types of services, and general delegation of responsibilities that will constitute the clinical practice.
The POP is a written commitment and agreement between Butte Silver–Bow Primary Health Care Clinic, Inc. (Community Health Center or CHC) and the licensed independent practitioner.

Development of the POP must be given serious thought and consideration. It covers many aspects of the clinic operation from services the health care professional will provide; to the role they will play in administrative matters. To prevent misunderstanding, everyone affected by its policies should participate in its review.

SPECIFIC OBJECTIVES

To document the services you are expected to provide.
To document the services others are expected to provide.
To specify your working hours and normal on-call rotations.
To clarify any administrative responsibilities you may have.
To encourage discussion between the CHC leadership and you regarding the clinic’s philosophy, its goals, and the community’s needs.
To maximize your knowledge and utilization of all available resources.
To meet part of the requirements of the Federal Tort Claims Act (FTCA) legislation. (i.e. outline services included in the scope of the CHC practice)

SECTIONS I AND II

Sections I and II list the most common components of a comprehensive primary health care delivery system.
In Sections I and II, an “X” is placed in the areas that best describe the practice expectations for the health care professional.

OTHER STAFF COLUMN

An “X” placed in the column titles "PROVIDED BY OTHER STAFF” indicates that services are provided by other staff members at the CHC. However, if necessary and appropriate, you will provide the service.

REFERRED COLUMN

An “X” is placed in the column titled “REFERRED” indicates services which are provided on a regular basis by formal arrangement with another agency and /or provider outside of the CHC. COMMENTS COLUMN

The “Comments Column” is utilized to provide additional information related to the service, so that the health care professional’s responsibilities are as clear as possible.

SECTION I

OFFICE BASED PRIMARY CARE SERVICES

	Provided by self	Provided by other staff	Referred	Comments
Primary Care Services
Pediatric Well Child Exam
Pediatric Care
Adolescent Health
Adult Health Maintenance
Adult Medical
Geriatric Health
Perinatial Care
Uncomplicated Deliveries
Family Planning/GYN
Emergency Services				Life threatening emergencies are referred to the emergency room at the local hospital
Minor Office Surgery				Depending on need, patient may be referred
Trauma				Assessed and referred
Office Surgery/Elective
Mental Health Counseling
Psychiatry
Disability Exam and Related Services
Worker’s Comp Exam and Related Services
Coverage for all CHC patients especially when the patient’s established provider is not on-site when the patient requires service
Dept. of Trans. Pre-employment exam
Supervises mid-level provider
Provide Primary Care Services to inmates of the County Jail
Laboratory				The CHC is licensed to perform the waived CLIA lab tests
Pharmacy				The CHC does have a licensed clinical pharmacy. We provide onsite education We provide sample medications and indigent drug program
X-ray				The CHC does not own or utilize x-ray equipment.
Nutrition				Provide basic information and referral
Health Education				Provide basic information and referral
Rehabilitation Services
Social Services
Occupational Health
Environmental Health

CLINIC PROCEDURES

Clinic procedures	Provided by self	Provided by other staff	Referred	Comments:
Endometrial Biopsy
Joint injection
Joint Aspiration
Toe nail removal
Sutures
Wart Removal
Incision and drainage
Excision Biopsy
PAP
Electrocautery Desiccation and Curettage
Other

***Circumcisions and EGD and Colonoscopy are NOT done at the clinic site.
*** Stress tests are NOT done at the clinic site.
***Lumbar punctures are not done at the clinic site.

SECTION II
NON-OFFICE BASED PRIMARY CARE SERVICES
Hospitals have their own privileging process outside of the CHC
All CHC MD’s are expected to provide hospital services as part of their employment with the CHC.

	Provided by self	Provided by other staff	Referred	Comments
Hospital services
Pediatrics				Patient care can be referred to the pediatricians and non-CHC providers
Newborn ICU
Internal Medicine				Patient care is referred to appropriate referral provider
ICU				“
CCU				“
Surgery				“
GYN				“
Surgical Assist
Emergency Rm call for CHC				Per agreement with community physicians or the local hospital
Emergency Rm. call for other patients				Per agreement with community physicians or the local hospital
Unassigned patients from the local Hospital				Per agreement with community physicians and hospital privileges
Provide services to chemical dependency patients				Provide patient exams. Referral to community services.
Nursing home
Home health
	Provided by self	Provided by other staff	Referred	Comments
School health services and related programs				CHC participates in collaborative services with the school nurses such as flu shots, sports physicals, and lice checks.
Community service and outreach				CHC collaborates with a variety of community social services to provide special events such as depression screenings, educational lectures etc.

SECTION III PRACTICE COVERAGE
SCHEDULE OF CLINIC BUSINESS HOURS

Butte CHC Medical Clinic is open from 8:00 A.M. to 6:00 P.M. Monday through Thursday and 8:00 A.M. to 5:00 P.M. on Friday. Butte Pediatric Providers have Saturday Clinic when on call.
Dillon CHC Clinic is open from 8:00 A.M. to 5:00 P.M.
Sheridan CHC Clinic is open from 8:00 A.M. to 5:00 P.M.
Note: As the practice grows, additional weekday, evening and weekend hours may be added.

AFTER HOUR CARE FOR BUTTE:

Butte dental patients calling after hours will go to the Butte Medical after hours call schedule.
Butte Medical – Butte adult medical providers (PA’s, FNP’s, MD’s, DO’s) will take phone call from 6:00 P.M. to 9:00 P.M. Monday through Thursday and from 6:00 P.M. through Monday 8:00 A.M. When the Butte clinic closes for the evening the phones are turned over to a contracted answering service.

IN PATIENT/HOSPITAL CALL

Butte adult medical patients are covered by the Sound Inpatient Physicians at St. James Hospital that are under contract agreement. The hospital will fax admit and discharge summaries to the CHC and all out patient care takes place by the CHC providers.
DILLON PROVIDERS WHO ARE ESTABLISHED IN A PRACTICE SHARING ON-CALL

When the on-call physician treats someone who is established in another practice, the patient will be cared for and invoiced by the practice of the on-call physician.
While the physician is on-call, the patient will be treated by the on-call physician.
In most cases when the treating physician’s on-call time is completed, the treating physician will turn the patient over to the care of the physician with whom the patient is established.
In cases where the patient is nearing discharge, the on-call physician may continue care. In situation like this the on-call physician and established physician decide how to handle the patient’s care.
The medical care of patients who are established with the CHC must be provided at the CHC. The provider working on-site when the patient requires medical care is responsible for providing the care.

DILLON AND SHERIDAN COVERAGE DURING NON-OFFICE HOURS; WEEKDAY; ON-CALL COVERAGE:

Contracted and community doctors share the on-call responsibilities for the CHC both weekday and week-end call.
Weekend call begins on Friday at 5:00PM and ends on Monday at 7:00 AM. Weekday call begins at 5:00 PM and ends the next morning at 7:00 AM.

BUTTE CHC OB PATIENTS

Obstetrical patients are cared for by, Dr. George Mulcaire-Jones and Dennis Salisbury of Rocky Mountain Clinic in Butte through a formal contract which covers hospital in patient and clinic services.
Dillon and Sheridan do not provide OB services at the clinic.

UNASSIGNED HOSPITAL PATIENTS AT ALL SITES

Patients admitted to the local Hospital, who have not established care with a local medical provider, are assigned to physicians who have admitting privileges at the local Hospital (“unassigned call”).
To maintain hospital privileges, each physician must participate in the on-call rotation. Presently the Butte CHC’s unassigned are contracted to Sound Inpatient Physicians.
Each physician rotates into the non-assigned patients on-call assignment as a condition of privileges at the hospital
Currently, the physicians in the on-call rotation discuss and agree upon the arrangements to cover the unassigned call for each other and a monthly call schedule is published.

SECTION IV
ORGANZATIONAL RELATIONSHIPS
FUNCTIONS AND AREAS OF RESPONSIBLILITES

ADVISES-has a formal advisory role and formal channel through which the advise is requested and provided
RESPONSIBLE-authorizing agent

AREA	BOARD OF DIRECTORS	CEO	HEALTH CARE DIRECTOR	HEALTH CARE PROFESSIONAL
Hires and discharges clinical staff		R	A	A
Hires and discharges administrative staff		R	A	A
Provide day-to-day leadership and direction for the medical practice and medical support staff		A	R	R
Function as a medical team leader, (communicates with staff regarding medical services, needs and medical provider expectations		A	R	R
Provide day-to-day leadership and direction for the CHC		R	A	A
Supervises the medical providers in their provision of medical services		A	R	A
Supervises the medical providers in the management related functions of medical services		R	A	A
Supervises medical support staff in conjunction with the medical director		R	R	A

FUNCTIONS AND AREAS OF RESPONSIBILITIES

AREA	BOARD OF DIRECTORS	EXECTIVE DIRECTOR	HEALTH CARE DIRECTOR	HEALTH CARE PROFESSIONAL
Supervises administrative staff		R	A	A
Coordinates Medical and Quality Improvement Plan		R	R	A
Coordinates general and administrative staff meetings		R	A	A
Approves personnel policy	R	A	A	A
Establishes/changes staffing patterns		R	A	A
Establishes /changes fee schedules	R	A	A	A
Develops budgets		R	A	A
Approves budget	R
Approves changes to credit and related collection policies	R	A
Approves purchases within the budget		R	A	A

The Leadership Team has reviewed these documents and met with the health care provider to recommend approval of scope to the Board of Directors.

This Principles of Practice will remain in effect from the date of this document for two years or as it becomes necessary to revise it.

Agreed to by:

___________________________________________________________________________________________________
Health Care Provider Date

___________________________________________________________________________________________________
Health Care Director Date

___________________________________________________________________________________________________
CEO Date

Reviewed by Leadership committee:

Date:_________________________________________________________________

Hours of Operation
Monday thru Friday
8:00am to 6:00pm

For Appointments
406-723-4075
406-723-3059 (Fax)

Our Location
445 Centennial Avenue
Butte, Montana 59701

SPECIFIC OBJECTIVES

SECTIONS I AND II

OTHER STAFF COLUMN

REFERRED COLUMN

FUNCTIONS AND AREAS OF RESPONSIBILITIES