exercises privileges at that Hospital , or is an applicant for medical staff membership or privileges . Disclosure shall be limited to the information requested and express written consent by the practitioner must be received .
( 2 ) Non-Routine Requests for Information . If a practitioner has encountered disciplinary or peer review problems or been denied privileges at the Hospital , then no information shall be released until a copy of a signed release , deemed satisfactory by legal counsel , has been received from the requesting institution . Additionally , all responses to such requests shall be reviewed and approved by the Chief of Staff , who may consult with legal counsel . b .
Other Requests . All other requests by persons or organizations outside the Hospital for information contained in Medical Staff records shall be forwarded to the Chief of Staff and the Director of Medical Staff Services .
D . Subpoenas . All subpoenas of Medical Staff records shall be referred to the CEO , who shall consult the Chief of Staff , the CMO / VPMA , Renown legal counsel and the Director of Medical Staff Services .
RULE 5-1 Section 1 .
ORGANIZATION AND FUNCTIONS MANUAL Organization and Functions of the Staff
The medical staff shall be organized as a departmentalized staff . A Department Chair shall head each Department with overall responsibility for the supervision and satisfactory discharge of assigned functions under the MEC .
1.1 Responsibilities for Medical Staff Functions
The organized medical staff is actively involved in the measurement , assessment , and Hospital performance and patient safety improvement with the ultimate responsibility lying with the MEC . The MEC may create committees to perform certain prescribed functions . The medical staff officers , Department Chair , Hospital and medical staff committee chairs , are responsible for working collaboratively to accomplish required medical staff functions . This process may include periodic reports as appropriate to the appropriate department or committee and elevating issues of concern to the MEC as needed to ensure adherence to regulatory and accreditation compliance and appropriate standards of medical care .
1.2 Description of Medical Staff Functions
The medical staff , acting as a whole or through committee , is responsible for the following activities :
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