( d ) Additionally , if requested , the following may be required : relevant practitioner-specific data as compared to aggregate data and morbidity and mortality data .
( e ) An application will become incomplete if the need arises for new , additional , or clarifying information . Any application that continues to be incomplete 30 days after the applicant has been notified of the additional information required will be deemed to be withdrawn .
( f ) An incomplete application will not be processed .
( g ) Applicants and members are responsible for notifying the Medical Staff Office , in writing , of any change in status or any change in the information provided on the application form . This information is required to be provided with or without request , promptly but no later than ten days of the change occurring , and includes , but is not limited to :
( 1 ) any information on the application form ; ( 2 ) any threshold eligibility criteria for appointment or clinical privileges ;
( 3 ) complaints , documents or other information known to the practitioner regarding , or changes in , licensure status or DEA registration or state-controlled substance license ;
( 4 ) changes in professional liability insurance coverage ; ( 5 ) the filing of a professional liability lawsuit against the individual ;
( 6 ) the filing of any lawsuit or administrative complaint or proceeding by any government agency related to the individual ’ s professional practice ;
( 7 ) a criminal investigation involving the individual , arrest , charge , indictment , conviction , or a plea of guilty or no contest in any criminal matter other than a misdemeanor traffic citation ;
( 8 ) exclusion or preclusion from participation on any private health insurance panel of providers or in Medicare , Medicaid , or any other federal or state healthcare program , or any sanctions imposed with respect to the same ;
( 9 ) changes in status ( e . g ., appointment , clinical privileges , or employment ) at any medical group or health care entity because of issues with clinical competence or professional conduct ; and
( 10 ) any changes in the practitioner ’ s ability to safely and competently exercise clinical privileges or perform the duties and responsibilities of appointment
4877-0873-6192 , v . 3 10