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ASM Test - Reappointment Application
Introduction
Form Approved
OMB No. 0917-0009
Exp. Date 08/31/2023
Welcome to Indian Health Service
The Federal Health Program for American Indians/Alaska Natives
Our Mission: The overall mission of the Indian Health Service is to raise the physical, mental, and social and
spiritual health of American Indians and Alaska Natives (AI/AN) to the highest level.
Our Goal: To ensure that comprehensive, culturally acceptable personal and public health services are
available and accessible to American Indians & Alaska Native people.
Information and Tips for Completing the Reappointment Application
INSTRUCTIONS: Enter all pertinent information, as applicable. Fill out all required sections and
fields that are marked in Red; these are mandatory and must be completed to submit the
application. At any point, the application may be saved by clicking Save and completed at a later
time. The blue toolbar at the top right provides additional help. The definition of "applicant" within
this application is the individual requesting medical staff membership and/or clinical privileges.
Packet Documents included on the previous home screen are MANDATORY. These must be
viewed and/or filled out and uploaded into the Files section on this application.
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Please note that any documents that require electronic signature are found at the end of the
application.
The Head Icon at the top right allows the applicant to change or reset the password and
authorize account access to a delegate.
Help Icon provides support if technical difficulties are encountered.
Return To Application after submitting the application, where the completed application and
supporting documents may be viewed, downloaded, or printed.
UPLOADING DOCUMENTS: Completed documents and forms must be uploaded in the Files section
of this application. Please contact the Medical Staff Credentialing Coordinator for other delivery
methods if technical difficulties are encountered.
LENGTHY RESPONSES: Each text field in this application has a limit of two lines. If a response
exceeds two lines of text, please upload the response as a Word or PDF document in the Files
section of this application.
ATTENTION: Misrepresentations, inaccuracies, or falsification of any information may be grounds
for denial or termination of medical staff appointment and/or associated clinical privileges, and
may be subject to the reporting requirements of the National Practitioner Data Bank (NPDB), and
state and federal licensing boards.
INCOMPLETE APPLICATIONS & MISSING DOCUMENTS: Applications with incomplete information or
missing documents will be returned to the applicant and delay the processing of the application. If
the applicant does not respond within 30 days of the request and/or the time specified in the local
medical staff bylaws, the applications (initial or reappointment) will be deemed incomplete and
ineligible for processing. The applicant has the responsibility for furnishing information that will
help resolve any questions concerning these qualifications.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0917-0009. The time required to complete this
information collection is estimated to average 45 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, to review and
complete the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: Indian Health Services,
OMS/DRPC, 5600 Fishers Lane, 09E70, Rockville, MD 20857, Attention: Information Collections
Clearance Officer.
Personal Information
Review the current entries below and update information, as applicable.
Mandatory fields are in Red. Click Edit to modify the entry, and Save to save the information entered.
Prefix
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First Name
Middle Name
Last Name
Test
Suffix
Degree
Degree2
Degree3
Specialty 1
Specialty 2
Preferred Name
Birth Date
MM/DD/YYYY
SSN
-Gender
Birth Place
Citizenship
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Marital Status
Spouse Name
Pager
Answering Service
Cell
E-Mail
NPI
Preferred Contact Method
Language 1
Language 2
Save
Cancel
Addresses 0 of 1 Required
Review the current entries below and update information, as applicable.
Mandatory fields are in Red. Click Edit to modify an existing entry, Delete to delete an entry, and Add to
add a new entry. Click Save to save the information entered.
New Address*
Delete
Type
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Address1
Address 2
City
State
Postal Code
County
Country
Telephone
Fax
E-Mail
Save
New Addresses
Cancel
+ Add
Alias/Other Names Used
Review the current entries below and update information, as applicable.
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Mandatory fields are in Red. Click Edit to modify an existing entry, Delete to delete an entry, and Add to
add a new entry. Click Save to save the information entered.
Delete
New Alias*
AliasType
FamilyName
GivenName
OtherGivenName
Save
Cancel
New Alias/Other Names Used
+ Add
Education / Training
Review the current entries below and update any new education or training (including new college
degrees, residencies, fellowships, etc.) since last appointment, as applicable. State in the Comments
field if you completed the education/training. If you did not, please explain why.
If the exact start or end date is unknown, please ensure that the month and year are correct.
If a residency or fellowship was completed, please indicate the specialty and program name in the
Subject field. If internship information is submitted, please add if the internship was rotating, mixed, or
straight in the Subject box. If a straight residency was complete, please also include the discipline.
Mandatory fields are in Red. Click Edit to modify an existing entry, Delete to delete an entry, and Add to
add a new entry. Click Save to save the information entered.
New Education*
Delete
Type
SourceID
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Enter Name or City to search
Name
Address
Address 2
City
State
Postal Code
Reason for leaving
Telephone
Fax
Email
Website
Start Date
MM/DD/YYYY
End Date
MM/DD/YYYY
Degree Earned
Subject
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Comments
Save
New Education / Training
Cancel
+ Add
Hospital Affiliations
Review the current entries below and add any new healthcare organization information where medical
staff membership and/or privileges were granted (including employment, self-employment, or service
as an independent contractor) since since last appointment, as applicable.
DO NOT include fellowships, internships and/or residencies previously reported under
Education/Training.
Mandatory fields are in Red. Click Edit to modify an existing entry, Delete to delete an entry, and Add to
add a new entry. Click Save to save the information entered.
New Hospital*
Delete
SourceID
Enter Name or City to search
Name
Address
Address 2
City
State
Postal Code
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County
Telephone
Fax
Email
Website
Start Date
MM/DD/YYYY
End Date
MM/DD/YYYY
Specialty
Relationship
Supervisor
What is or was your medical staff status (active, temporary, provisional, etc.)?
Reason for leaving
Comments
Save
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Cancel
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New Hospital Affiliations
+ Add
Work History
Review the current entries below and add any current or past work history since last appointment, as
applicable.
DO NOT include organizations already listed in the Hospital Affiliations and Education/Training sections.
If a gap greater than 60 days exists between organizations, please add and explain in the Gaps section.
Mandatory fields are in Red. Click Edit to modify an existing entry, Delete to delete an entry, and Add to
add a new entry. Click Save to save the information entered.
New Work History*
Delete
Type
SourceID
Enter Name or City to search
Name
Address
Address 2
City
State
Postal Code
County
Country
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Telephone
Fax
Email
Website
Start Date
MM/DD/YYYY
End Date
MM/DD/YYYY
Position
Relationship
Supervisor
Reason for leaving
Comments
Save
New Work History
Cancel
+ Add
Peer Professional References 0 of 3 Required
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List names and contact information of at least three (3) individuals who have equal or greater
credentials, who are unrelated by blood or marriage, and have personal knowledge of the applicant's
current clinical abilities, ethical character, and interpersonal skills, within the last 24 months.
Please note that some facilities may require and request additional peer references.
Mandatory fields are in Red. Additional peer references may be added by clicking the Add button. Click
Save when finished.
New Peer Reference*
Delete
First Name
Last Name
Degree
Address
Address 2
City
State
Postal Code
Years Known
Telephone
Fax
E-Mail
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Relationship
Specialty
Save
New Peer Professional References
Cancel
+ Add
Licenses / Credentials
Review the current entries below and update or add any new credentials since last appointment, as
applicable.
All the following credentials listed below are required (please note that other credentials may be
required by the facility in which you are applying.):
1. ALL inactive and active professional state licenses
2. ALL inactive and active DEA, CDS, or other licenses or registrations.
3. Current life support certifications (Example: BLS, ACLS, ATLS, NRP, PALS, ALSO, etc.)
Please document any limitations or restrictions in the Status section.
The License Number and State fields are required to submit the application. If a license or credential
does not have a license number associated with it, please add N/A to the License Number field. If a
license or credential does not have a state associated with it, add a state that you are licensed in or
reside in. Please include any additional information in the Comments field.
Mandatory fields are in Red. Click Edit to modify an existing entry, Delete to delete an entry, and Add to
add a new entry. Click Save to save the information entered.
New Credential*
Delete
Type
Name
Address
Address 2
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Address 3
City
State
Postal Code
County
Country
Telephone
Fax
Email
Website
License Number
Issue Date
MM/DD/YYYY
Expiration Date
MM/DD/YYYY
State
Status
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Comments
Save
New Licenses / Credentials
Cancel
+ Add
Board Certifications
Review the current entries below and update or add any new board certification since last
appointment, as applicable. (Note that state licenses granted by state licensing boards should be added
in the Licenses/Credentials section.)
If not certified, please provide an explanation in the Comments section. Also document if an application
was submitted for board certification and the examination date, if applicable.
Mandatory fields are in Red. List your primary board certification first. Begin by clicking the ADD button,
and type the board acronym and/or name in the Search box. Once selected, it will pre-populate fields.
New Board Certification*
Delete
SourceID
Enter Name or City to search
Name
Address
Address 2
Address 3
City
State
Postal Code
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County
Country
Telephone
Fax
Email
Website
Certification Status
Certificate Number
Initial Certification
MM/DD/YYYY
Recertification
MM/DD/YYYY
Expiration Date
MM/DD/YYYY
Exam Date
MM/DD/YYYY
Specialty
Certified In
Comments
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Save
New Board Certifications
Cancel
+ Add
Medical Societies
Review the current entries below and update or add any new medical society memberships since last
appointment, as applicable.
Mandatory fields are in Red. Click Edit to modify an existing entry, Delete to delete an entry, and Add to
add a new entry. Click Save to save the information entered.
New Society*
Delete
SourceID
Enter Name or City to search
Name
Address
Address 2
City
State
Postal Code
County
Country
Telephone
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Fax
Email
Website
Start Date
MM/DD/YYYY
End Date
MM/DD/YYYY
Title
Save
Cancel
New Medical Societies
+ Add
Malpractice Coverage
Review the current entries below and update or add any new malpractice coverage since last
appointment, as applicable.
Mandatory fields are in Red. Click Edit to modify an existing entry, Delete to delete an entry, and Add to
add a new entry. Click Save to save the information entered.
New Insurance*
Delete
SourceID
Enter Name or City to search
Name
Address
Address 2
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City
State
Postal Code
County
Country
Telephone
Fax
Email
Website
Policy Number
Issued Date
MM/DD/YYYY
Expiration Date
MM/DD/YYYY
Retroactive Date
MM/DD/YYYY
Coverage
Terms
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Save
New Malpractice Coverage
Cancel
+ Add
Malpractice Claims
Provide information regarding any current (open or pending) and previous lawsuits or complaints
against the applicant or a hospital, corporation, or the United States Government based on a case with
which the applicant is or was professionally associated since last appointment, as applicable. External
verification (i.e., statement from an attorney, court records, etc.) may be requested.
Begin by clicking Add, then type in the insurance company name associated with the incident in the
Insurance ID box, and the healthcare organization where the incident occurred in the Healthcare
Organization ID box. Once selected, the fields will prepopulate. If the status of the malpractice claim is
not available under Status, please provide the information in the Status Comments box. If the Status
selected is "Settled," please place the settlement amount in the Amount field. Click Save when finished.
The Notes section is limited to 300 characters. If a response is more than 300 characters, upload the
information as a Word or PDF document in the Files section
New Malpractice Claim*
Delete
IncidentDate
MM/DD/YYYY
DateFiled
MM/DD/YYYY
DateClosed
MM/DD/YYYY
Amount
Type
Status
Notes
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Allegation
Status Comments
InsuranceID
Enter Name or City to search
Insurance Name
InsuranceAddress
InsuranceAddress2
InsuranceCity
InsuranceState
InsurancePostalCode
InsuranceCountry
InsuranceTelephone
InsuranceFax
HospitalID
Enter Name or City to search
Hospital Name
HospitalAddress
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HospitalAddress2
HospitalCity
HospitalState
HospitalPostalCode
HospitalCountry
HospitalTelephone
HospitalFax
Save
New Malpractice Claims
Cancel
+ Add
Files
Upload the following required documents. Note that some forms may not be required by some
facilities. Forms that require signature are either housed on the login screen, at the end of the
application for electronic signature, or will be emailed to you.
1. CMEs since last appointment
2. Completed Statement of Understanding & Release Form
3. Completed Health Statement Form (MUST be uploaded to submit application.)
Please upload the following, if applicable:
1. IHS Opioid Prescriber Training Certificate (if renewed since your last appointment)
2. Copies of life support certifications (if renewed since your last appointment)
3. Any new malpractice claims information since your last appointment (if applicable)
4. Current curriculum vitae or resume (if any new affiliations since your last appointment)
5. Application Approval Signature Page (electronic signature of this application will suffice)
6. Delineation of Privileges Signature Page (electronic signature of this application will suffice)
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7. Any other documents in the download section or provided to you by email
To upload a digital document (pdf, jpg, etc):
1. Select Add
2. Select a File Type
3. Enter a Description (Optional)
4. Click on Click To Upload to browse for the file
5. Click Save to complete the upload
If unable to perform a document upload, please contact MD-App Support at 1-800-736-7276 or the
Medical Staff Office.
Delete
New File*
FileType
Expiration Date
MM/DD/YYYY
FileDescription
Upload File
Click to Upload
Save
New Files
Cancel
+ Add
Attestation Questions
Please answer **ALL** attestation questions. For any "Yes" answers, please explain in the space
provided.
Yes
No
Has your license to practice in any jurisdiction ever been or ever
attempted to have been denied, restricted, limited, suspended,
revoked, canceled, reprimanded, or censured, and/or have you
ever practiced without a license?
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Yes
No
Has your license to practice ever been subject to probation, either
voluntarily or involuntarily?
Yes
No
Has your license ever been voluntarily or involuntarily withdrawn?
Yes
No
Has any disciplinary actions or investigations ever been initiated
against you by any state licensure board?
Yes
No
Have you ever been reprimanded and/or fined, by any local, state,
or federal agency that licenses providers?
Yes
No
Have you ever been the subject of an informal or formal hearing
process at any healthcare organization?
Yes
No
Have you ever been the subject of a complaint, or have you ever
been notified in writing that you have been investigated as the
possible subject of a criminal or civil action by any state or federal
agency that licenses providers?
Yes
No
Have you ever been notified in writing that you are being
investigated as the possible subject of a criminal or disciplinary
action by any health care organization (e.g., hospital, HMO, PPA,
IPA), professional group or society, licensing board, certification
board, PSRO or PRO?
Yes
No
Have you ever been cautioned, reprimanded, or disciplined by any
institution, any local, state, or national professional society,
regulatory agency, or place of employment?
Yes
No
Has your employment and or clinical privileges at any hospital,
clinic, or other health care setting ever been denied, suspended,
revoked, reduced, restricted, not renewed, voluntarily or
involuntarily relinquished, denied renewal, or has probation ever
been invoked?
Yes
No
Have you ever voluntarily or involuntarily withdrawn your
application for clinical privileges or terminated clinical privileges
prior to a hospital or health facility's governing board's final
decision?
Yes
No
Have you ever been reprimanded, censured, excluded, suspended,
disqualified and/or participation voluntarily withdrawn, to avoid an
investigation by Medicare, Medicaid, TRICARE, and/or any other
governmental health related programs?
Yes
No
Have Medicare, Medicaid, TRICARE, PRO authorities, and/or any
other third party payers ever brought charges against you for
alleged inappropriate fees, and/or quality of care issues?
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Yes
No
Has any information pertaining to you, including malpractice
judgements and/or disciplinary action, ever been reported to the
National Practitioner Data Bank or any other practitioner data
bank, or any other federal or state board oversight authority?
Yes
No
Has your federal DEA number, state controlled substance license,
or other controlled substance license ever been suspended,
revoked, restricted, limited, or relinquished either voluntarily or
involuntarily?
Yes
No
Have you ever been notified in writing that you are being
investigated as the possible subject of a criminal or disciplinary
action with respect to a DEA or other controlled substance
registration or license?
Yes
No
Have you ever had a claim for professional negligence asserted
against you? If yes, you are required to note your final judgement
and settlements in the Malpractice Claims section of this
application.
Yes
No
Have liability claims, judgements or settlements ever been made
against a hospital, corporation, or the United States Government in
professional liability suits based on a case with which you were
professionally associated? If yes, you are required to note the final
judgement and settlements involving yourself as a practitioner in
the Malpractice Section of this application.
Yes
No
Have you ever had professional liability coverage denied, refused,
or canceled by a professional liability insurance company?
Yes
No
Have you ever withdrawn from or been suspended, dismissed or
expelled from a professional school or postgraduate training
program, or has any third party ever attempted to have you
withdrawn, suspended, dismissed, or expelled from a professional
school or postgraduate training program?
Yes
No
Have you ever been placed on probation or taken a leave of
absence from medical, dental, or other graduate school or
postgraduate training program?
Yes
No
Have you ever been the subject of a civil or criminal complaint or
administrative action, or are you being investigated as the possible
subject of a civil, criminal, or administrative action regarding sexual
misconduct, child abuse, domestic violence, elder abuse, or any
other violent crimes?
Yes
No
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Do you currently have, or has it ever been suggested to you that
you have any physical, mental, or emotional impairment that you
or an objective third party might think would limit your ability to
meet the duties associated with clinical staff membership and
which could require an accommodation for you to exercise your
clinical privileges and clinical staff duties completely and safely? If
yes, please describe the accommodation needed.
Yes
No
Do you have, or has it been suggested to you that you have, a
diagnosed or undiagnosed chemical dependency (i.e. alcohol,
illegal drugs, prescriptive drugs, etc)?
Yes
No
Are you currently engaged in illegal use of any legal or illegal
substances?
Yes
No
Are you currently participating in a supervised rehabilitation
program and/or professional assistance program, which monitor
you for alcohol and/or substance abuse.
Yes
No
Has it been more than 12 months since you have provided patient
care in a professional setting?
Yes
No
Have you ever been charged with or convicted of a crime, other
than a minor traffic offense, in any state or country?
Yes
No
Were you ever the subject of any disciplinary action at any
educational (college) or training (residency, fellowship, internship,
etc.) programs?
Yes
No
Do any health problems exist that could affect your ability to
perform the privileges requested?
Yes
No
I have an impairment that affects my ability to perform the clinical
privileges requested and for which I require accommodation.
Certification of Professional Licenses
Yes
No
I certify that I have listed all active and inactive state medical
licenses and controlled substance registrations/licenses on this
application.
Yes
No
I certify that my professional licenses and certifications (nurse,
medical, dental, or other health profession) have not been
terminated, suspended, or revoked in any state or a territory of the
United States.
Yes
No
I certify, as required by the false statements provisions of the
Program Fraud Civil Remedies Act of 1986, 45 Code of Federal
Regulations (CFR) 79, that to the best of my knowledge, each of the
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above statements are true, accurate, and do not omit any material
or facts which would render the statement false, fictitious, or
fraudulent as a result of omission.
Privileges
Request privileges below by checking the blue Request check box on the left side of the screen.
Currently approved privileges are denoted as "Granted" below the blue box. If you do NOT want to
renew a specific privilege, please do NOT check the blue Request box.
Review Application
Final Steps:
1. Read the Applicant’s Certification Statement:
By signing this application, I certify that all the information submitted by me in this application is
true and complete to the best of my knowledge. I agree to immediately disclose to the governing
body if any answer to a question above becomes “Yes” while or staff membership and/or
privileges are pending or have been granted. I agree to abide by all lawful standards, policies,
rules, regulations, and bylaws of the facility, the Area, the Indian Health Service, the U.S. Public
Health Service, and the Department of Health and Human Services, as they apply to my
responsibilities and practice as a member of the clinical staff. I further agree to answer any
questions concerning the contents of this application either during the application process or
subsequent to having been granted privileges. I agree that inquiries may be made to any federal
or private sector facility with which I have been affiliated. I pledge to maintain an ethical practice
and to provide for the continuous care of all my patients.
2. Click Submit Application. (Once the application has been submitted, you may go back to edit your
data by clicking Unsubmit on the main login page. You may also print the application by clicking
View Application.)
3. On the Electronic Signature page enter your complete and legal name, check the box indicating
that you have read and agree to be bound by the Applicant’s Certification Statement, and that to
the best of your knowledge, all information provided on the application is true and accurate, and
that no material or facts which would render the statement false, fictitious, or fraudulent is
omitted.
The application is incomplete
Submit Application
10.155.162.10/mdapp/ihs-test//Application/Details/6b6f78ea-26ea-4cfd-aa32-b93572f9a099
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| File Type | application/pdf |
| File Modified | 2023-04-13 |
| File Created | 2023-04-13 |