ARTICLE 3 PROCEDURE FOR INITIAL APPOINTMENT AND PRIVILEGES
3. A. APPLICATION 3. A. 1. Application Form:
( a) Application forms for appointment, reappointment, and clinical privileges will be approved by the Board, upon recommendation by the Credentials Committee and MEC.
( b) The applications for initial appointment, reappointment, and clinical privileges existing now, and as may be revised, are incorporated by reference and made a part of this Manual.
( c) The application will contain a request for specific clinical privileges and will require detailed information concerning the applicant’ s professional qualifications. The applicant will sign the application and certify that they are able to perform the privileges requested and the responsibilities of appointment.( 1) if an applicant is unable to perform a privilege essential to practice due to a documented ADA condition, they must provide certification of the ADA-related condition to be reviewed.
( d) In addition to other information, the following may be considered:
( 1) information as to whether the applicant’ s appointment, membership, or clinical privileges have been voluntarily or involuntarily relinquished, withdrawn, denied, revoked, suspended, subjected to probationary or other conditions, reduced, limited, terminated, or not renewed at any other hospital, health care facility, or other organization, or are currently being investigated or challenged;
( 2) licensure status in all current or past states of licensure and whether that licensure has been voluntarily or involuntarily suspended, modified, terminated, restricted, or relinquished or is currently being investigated or challenged;
( 3) information, evaluated on a case by case basis, as to whether the applicant’ s DEA registration, or any state’ s controlled substance license has been voluntarily or involuntarily suspended, modified, terminated, restricted, or relinquished or is currently being investigated or challenged;
( 4) information from the AMA or AOA Physician Profile;
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