providence hospital live smart. live healthy...
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ProvidenceHospitalLive Smart. Live Healthy. CREDENTIALING FORM
□ Informed□ Bizbox□ List of Consultant□ Letter of Appointment
Name of Applicant Department Specialty
CATEGORY APPLIED:
REQUIREMENTS:
REQUIREMENTS:
LYSANDER P. RAGODON, MD, FPCP, MHSA DAVE B. TAN, MD
□ Active Consultant □ Hospitalist □ Industrial Medicine□ Visiting Consultant □ Associate Consultant □ ER Consultant
□ Application Approved□ Application Declined
__________________________________ __________________________________Section Head Department Chairman
Medical Director President and CEO
Date Received: ________________________________ Date of Appointment: ___________________________
□ Letter of application (addressed to Dr. Tan)*
□ Accomplished application form
□ Recent photo (2x2)
□ Medical School Diploma
□ Physician Licensure Board Certificate
□ Certificate of Completion Residency training
□ Certificate of Completion of Sub-specialty / Fellowship training and other certifications for specialized procedures
□ Specialty and Sub-specialty Board Certificate
□ PRC ID (Number & Expiration Date): _______________________________________
□ Philhealth ID (Number & Expiration Date): _______________________________________
□ Photocopy of updated PTR
□ S2 license (for all hospitalists and the following specialties: Emergency Medicine, Anesthesia and Pain Management,Medical Oncology, Cardiology, Gastroenterology, Neurology, Geriatrics, Pulmonary Medicine and Critical Care): _____________________________________________
□ Photocopy of updated Life Support Certification _____________________________________________
□ TIN # ________________________________________
□ Philippine Medical Association (PMA) ID
□ Philippine Dental Association (PMA) ID
□ Data Privacy Policy Form
□ FOR ACTIVE: Privileging Form
ProvidenceHospitalLive Smart. Live Healthy.
MEDICAL STAFF APPLICATION FORMPlease print and write legibly
Name of Institution / AddressPls. use registered name upon graduation or certi�cation for veri�cation purpose
EDUCATIONAL / TRAINING BACKGROUND
CERTIFICATION
Pre-Medical Education
Medical Education (Doctor of Medicine)
Internship Hospital
Residency Training
Fellowship Training
Additional Training
ACLS / NALS
Additional certi�cation / s:
Specialty Board Certi�cation (Diplomate)
Sub Specialty (Diplomate) Board Certi�cation
Basic Life Support
Philippine Board of Medicine
Specialty: Subspecialty:
Present Address: Office No.:
Permanent Address: Mobile No.:
Date of Birth: Philhealth #(validity) Email address:TIN #
PRC # PMA # Referred by:S2 # (validity)
Age: Civil Status: Place of Birth: Religion:Gender:
Name: Home No. :
(First Name) (Middle Name) (Last Name) (Nickname)
Date applied: ________________ Control Number: ________________
RecentPhoto
From To
Date Awarded
ACADEMIC EXPERIENCE
CURRENT MEDICAL STAFF MEMBERSHIP IN OTHER HOSPITALS / CLINICS
PAST POSITIONS IN OTHER HOSPITALS / CLINICS
REFERENCE
Institution / Address Current and Past Position / Academic Rank Inclusive Dates
Institution / Address Position Date of Affiliation
Institution / Address Position Date of Affiliation
( Those who ca vouch for your moral character & integrity, include the Department Head or the Training Officer where you graduated from Residenct / Fellowship / the Medical Director / Department Chairman where you are currently affiliated / were last connected with )
Name Designation Institution Contact Number
Name Relationship Address Contact Number
Person to notify in case of emergency or illness ( Indicate relationship, address & telephone no. )
RECOMMENDATION:
RECOMMENDATION:
□ Application Approved □ Application Declined
__________________________________ __________________________________ __________________________________Section Head Department Chairman Chairman Credential Committee
□ Application Approved □ Application Declined
__________________________________ __________________________________ __________________________________Assistant Medical Director Medical Director President and CEO