REQUEST FOR HOSPITAL PRIVILEGES -- VOLUNTARY PRACTITIONERS Thank you for your interest in applying to the Medical Staff at Northwell Health. In order to request privileges at any hospital within Northwell Health, you will need to submit a copy of your current Curriculum Vitae in month and year format (mm/yyyy) with start and end dates of all listed affiliations, and provide us with the following information: Name: Title Last Name, First Name, Middle Initial e.g. MD, DO, DDS Date of Birth: SS#: Contact Address: Contact Telephone Number: Private Practice Address (required) Email Address (required): Your request should be addressed to the Clinical Integration Network IPA along with your current Curriculum Vitae and either fax, e-mail or mail it to: Clinical Integration Network IPA, LLC 600 Community Drive, Suite 404, Manhasset, NY 11030 Email: ciipa@northwell.edu Telephone: (800) 381-6140 Fax Number: (516) 321-8077 Once the requested information is received, the application process will begin. An Initial Application Packet will be sent to you within two (2) business days of receipt of your information or upon receipt of the authorization to release from the Department Chairman. This packet must be completed and returned to us as soon as possible, no later than seven (7) business days from the date of receipt. If you have any questions, please feel free to contact the Clinical Integration Network IPA at (800) 381-6140, Monday through Friday, 9:00 am to 5:00 pm. The below application fees are due at the time of submission of your application. FACILITY APPLICATION FEE Maimonides Medical Center Not Applicable Peconic Bay Medical Center $350 for Physicians / $175 for Allied Health Professionals All Other Northwell Health $200 per provider for the first two facilities & $50 for each additional Facilities
BOARD CERTIFICATION Primary specialty: Certification Date: / / If you are not board certified, are you board admissible? yes no Sub-specialty: Certification Date: / / If you are not board certified in your sub specialty, are you board admissible? yes no FACILITY DEPARTMENT LISTING This section is used to identify the actual facility/ies to which you would like to apply and includes a description of the applicable department specific requirements. Each applicant must meet the department specific requirements in order to be eligible to apply to that department. Please check next to each facility you would like to apply and the corresponding department. Please note that you will be sent the appropriate Delineation of Privilege form based on the department and specialty that you have selected. [ ] GLEN COVE HOSPITAL [ ] Dentistry [ ] Pathology [ ] Radiation Medicine
[ ] HUNTINGTON HOSPITAL [ ] Family Practice [ ] Orthopaedics [ ] Pathology [ ] LENOX HILL HOSPITAL * [ ] HealthPlex Only [ ] Cardiothoracic Surgery [ ] Cardiovascular Medicine [ ] Community and Acute Care Services (Healthplex) [ ] Neurosurgery [ ] Ophthalmology [ ] Otolaryngology - Head and Neck Surgery [ ] Pathology [ ] Plastic Surgery [ ] Radiation Medicine *Applicants wishing to apply to Lenox Hill Hospital must be approved by the Chairman of the Department you are applying to prior to having an application sent. Medical Staff Services will contact the Department Chairman to obtain your approval. [ ] LONG ISLAND HOME* Site: [ ] South Oaks Hospital [ ] Broadlawn Manor Nursing and Center *Applicants wishing to apply to the Long Island Home must be approved by the Medical Director of the LIH Site you are applying to prior to having an application sent. Medical Staff Services will contact the Medical Director to obtain your approval.
[ ] LONG ISLAND JEWISH MEDICAL CENTER [ ] Cardiovascular and Thoracic Surgery [ ] Dental Medicine [ ] Dermatology [ ] Neurosurgery [ ] Ophthalmology** [ ] Otolaryngology and Communicative Disorders [ ] Occupational Medicine, Epidemiology and Prevention [ ] Radiation Medicine * * Applicants for the Department of Surgery, Division of Plastic Surgery must be approved and interviewed by the Chairman of the Department prior to having an application sent. Medical Staff Services will contact the Department Chairman to obtain your approval. ** Applicants requesting privileges in Ophthalmology at North Shore University Hospital, Long Island Jewish Medical Center and/or Syosset Hospital must request privileges at all 3 sites. Applicants must be approved and interviewed by the Chairman prior to having an application sent. Medical Staff Services will contact the Department Chairman to obtain your approval. [ ] LIJ - FOREST HILLS CAMPUS [ ] Cardiovascular and Thoracic Surgery [ ] Dental Medicine [ ] Ophthalmology [ ] Otolaryngology * * Applicants for the Department of Surgery, Division of Plastic Surgery must be approved and interviewed by the Chairman of the Department prior to having an application sent. Medical Staff Services will contact the Department Chairman to obtain your approval.
[ ] LIJ VALLEY STREAM CAMPUS [ ] Orzac Center for Extended Care & [ ] Dental Medicine [ ] Neurosurgery [ ] Ophthalmology [ ] Otolaryngology * *Applicants for the Department of Surgery, Division of Otolaryngology at Franklin Hospital must also apply to Orzac. [ ] NORTH SHORE UNIVERSITY MEDICAL CENTER (Manhasset) [ ] Stern Family Center for Extended Care and [ ] Cardiovascular and Thoracic Surgery [ ] Dental Medicine [ ] Dermatology [ ] Neurosurgery [ ] Ophthalmology** [ ] Otolaryngology and Communicative Disorders [ ] Occupational Medicine, Epidemiology and Prevention [ ] Radiation Medicine * * Applicants for the Department of Surgery, Division of Plastic Surgery must be approved and interviewed by the Chairman of the Department prior to having an application sent. Medical Staff Services will contact the Department Chairman to obtain your approval. ** Applicants requesting privileges in Ophthalmology at North Shore University Hospital, Long Island Jewish Medical Center and/or Syosset Hospital must request privileges at all 3 sites. Applicants must be approved and interviewed by the Chairman prior to having an application sent. Medical Staff Services will contact the Department Chairman to obtain your approval.
[ ] NORTHERN WESCHESTER HOSPITAL [[ Anesthesia [ Emergency Medicine [ ] Pathology [ ] Radiation Oncology [ ] Surgical Services * All admitting applicants are required to participate in the hospital on call schedule. Any questions or concerns regarding an applicant s on call obligations should be discussed with the Chairman or Division Chief of the Department. [ ] PHELPS MEMORIAL HOSPITAL CENTER (Including subspecialties, Hospital Medicine) [ ] Radiation Medicine ( Including all surgical specialties) [ ] PLAINVIEW HOSPITAL [ ] Emergency Services [ ] Family Practice Specialty you intend to practice:
[ ] SOUTHSIDE HOSPITAL [ ] Cardio-Thoracic Surgery [ ] Orthopaedics [ ] Pathology (Contracted Service) [ ] Radiation Medicine [ ] Staten Island UNIVERSITY HOSPITAL* [ ] Anesthesiology [ ] Dentistry and Behavioral Sciences [ ] Radiation Oncology [ ] Medicine ** * Applicants wishing to apply to Staten Island University Hospital must be approved by the Chairman of the Department you are applying to prior to having an application sent. Medical Staff Services will contact the Department Chairman for your approval. If approved, an interview with the Chairman will be required. ** In order to apply to Medicine, you must be affiliated with the Departmental PC.
[ ] SYOSSET HOSPITAL [ ] Emergency Services [ ] Gynecology [ ] Laboratory Medicine/Pathology ** Applicants for the Department of Surgery, Division of Ophthalmology at North Shore University Hospital, Long Island Jewish Medical Center and/or Syosset Hospital must request privileges at all 3 sites. Applicants must be approved and interviewed by the Chairman prior to having an application sent. Medical Staff Services will contact the Department Chairman for your approval. [ ] MAIMONIDES MEDICAL CENTER [ ] Laboratory Medicine/Pathology [ ] Obstetrics & Gynecology [ ] Orthopedic Surgery [ ] Radiation Oncology [ ] PECONIC BAY MEDICAL CENTER [ ] Emergency Medicine [ ] Obstetrics & Gynecology [ ] Pathology [ ] Radiology