Get University Of Rochester Medical Center Request For Temporary Hospital Privileges 2012-2025

Filling out the University Of Rochester Medical Center Request For Temporary Hospital Privileges form is a crucial step in obtaining temporary hospital privileges. This guide will walk you through the comprehensive process, ensuring that you provide all necessary information correctly and efficiently.

Follow the steps to successfully complete your request for temporary hospital privileges.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your personal information in the designated fields, including your full name and contact details. This information should match your professional identification documents.
3. You will need to attach your professional license(s), current curriculum vitae (CV), DEA information (if applicable for anesthesiologists), and a clear photo ID. Ensure that all documents are up to date.
4. Complete and sign the Delineation of Privileges section. This form must have approval from the appropriate Department Chair before submission.
5. Provide the name of a reference who can attest to your current competence. Ensure that this individual is aware they may be contacted.
6. Include proof of your current Faculty Appointment, along with current malpractice insurance documentation, unless you are being covered through URMC.
7. Fill out the section describing any recent health reviews, PPD test results, Flu Vaccine Declination, Drug Screening, and Respiratory Fit Test, if applicable.
8. Indicate the reason for requesting temporary privileges by checking the appropriate box, such as locum tenens or emergency patient care needs.
9. Clearly state the name of the physician for whom you will provide emergency coverage in the designated area.
10. Sign the application where required, confirming your request for temporary Medical Staff Privileges and the department for which you are requesting privileges.
11. Include a justification statement explaining why the temporary privileges are necessary. Be concise but clear about the circumstances.
12. Submit the application to the Medical Staff Office, Box 278911, once all fields and required documents are completed. You can save changes, download, print, or share the form as needed during this process.

Ensure to complete your request for temporary hospital privileges online today to meet your professional needs.