Reappointment Application - Active Reciprocal

Reappointment Application - Active Reciprocal (July 1, 2024 to June 30, 2025)

Instructions

Please complete the following reappointment application.

Make sure you have proof of your documentation, membership with the Canadian Medical Protective Association (CMPA) or evidence of professional liability insurance coverage to submit with your application as you will be asked to upload. (Group Health Centre provides a copy of their physician’s insurance coverage therefore GHC physicians do not need to attach)

You will not be able to save this application and return to add your documentation.

I, hereby apply for reappointment to the medical staff of the Sault Area Hopsital,(Required)

(enter your name)

With privileges in the department of:(Required)

As a member of the following category of medical staff:(Required)

Please indicate any CHANGES to the following information:

Home Address

Home Phone

Office Address

Office Phone

Mobile Phone

Pager Number

Fax Number

In applying for reappointment I am requesting privileges as approved and attached to my previous application with the following changes (additions or deletions):

Education

In making this application, I provide the following record of my continuing education and contribution to the hospitals' operation:

1. Continuing Medical Education:

Did you satisfy the requirements of the CPSO for Continuing Medical Education participation as outlined by either the CFPC or the RCPSC at the time of your last renewal of licensure in Ontario?

Yes

2. Participation in Hospital Operations: (Active and Associate Staff)

A. Attendance at Medical Staff Meetings: Number attended

B. Attendance at your department's business meetings: Number attended

C. Staff and committee appointments held at the hospital in the current year:

3. Service to Other Hospitals and Health Organizations During the Past Year:

(Other Health Organizations include the O.M.A., local allied health groups,etc.)

Please identify positions held, committee representation and organization:

Professional Conduct

4. Have you been the defendant in any malpractice litigation or any litigation related to the practice of medicine during the past five (5) years in which a finding of negligence was made against you or in which negligence was admitted by you or on your behalf?

Yes

As the answer is YES to question 4, please provide details related to when, where, the circumstances regarding your involvement, and the disposition of the action.(Required)

5. Since July 1st of last year, have you ever been found guilty of professional misconduct?

Yes

6. Since July 1st of last year, have you ever agreed to a settlement to avoid anyproceeding or disciplinary action in respect of your professional conduct?

Yes

7. Since July 1st of last year, have you been the subject of an investigation by any licensing body in Ontario, or anywhere else?

Yes

As the answer is YES to question 7, please attach documentation indicating the reason for and the current status of the investigation.(Required)

Drop files here or

Max. file size: 100 MB.

8. Since July 1st of last year, has your name been placed on a list restrictingyour purchasing or prescribing of narcotic or restricted drugs?

Yes

9. Are you currently suffering from a condition that impairs your ability to practice medicine? A condition that impairs your ability to practice medicine means a condition that adversely affects your judgment or your ability to practice medicine in a safe, competent, ethical and professional manner. Conditions that are being treated such that they do not impair your ability to practice medicine do not need to be disclosed. You should consult with your treater(s) if you are uncertain if your condition is being sufficiently treated and does not require disclosure.

Yes

Note: SAULT AREA HOSPITAL recognizes that physicians, like their patients, experience physical and mental health conditions. Physicians should seek treatment, as needed, to ensure they are not practicing medicine while impaired. Resources available to physicians suffering from a medical condition include the OMA’s Physician Health Program, which provides confidential support (https://php.oma.org), as well as a variety of supports set out on the Physician Wellness page of the CPSO’s website (https://www.cpso.on.ca/en/Physicians/Your-Practice/Physician-Advisory-Services/Physician-Wellness ). Additionally, applicants are advised that disclosure of any medical conditions in this credentialing application will be kept in strict confidence and will only be used to evaluate what privileges will be granted to a physician for the upcoming credentialing year.

10. Since July 1st of last year, have you been convicted of a criminal offence inCanada or else where for which you have not received a pardon?

Yes

As the answer is YES to question 10, please provide information regarding the reason for and the current status of the conviction.(Required)

11. Since July 1st of last year, have you been charged with any criminal offences in Canada or elsewhere that currently remain outstanding?

Yes

As the answer is YES to question 11, please provide information regarding the reason for and the current status of the charges.(Required)

Emergency Contact Information

This information is helpful if the hospital needs to contact someone on your behalf:

Name

Surname (last name) Given name(s)

Relationship to Applicant

Phone (daytime)

Phone (other)

Home Address

Street Address Address Line 2 City Province Postal Code

Requirements

Please check your medical staff category to determine additional submission requirements:(Required)

Physicians

Midwives

NOTE: Please attach a copy of your current professional liability insurance coverage satisfactory to the Board. (Group Health Centre provides a copy of their physician’s insurance coverage therefore GHC physicians do not need to attach.)

Physicians:

Drop files here or

Max. file size: 100 MB.

Membership in the Canadian Medical Protective Association (CMPA), or evidence of individual insurance.

Midwives:

Drop files here or

Max. file size: 100 MB.

Please attach evidence of professional liability insurance coverage satisfactory to the Board.

Sault Area Hospital Medical Directives

Check the medical discipline(s) relevant to your practice. The 'All Physician' Directives listed are applicable to all physicians. Once reviewed please, sign where indicated.

Check applicable discipline(s) the relevant directives will be listed below.(Required)

All surgeons must select Surgeons [All] and their respective discipline if applicable.

All Physician Directives

GEN 02 Automated External Defibrillator

GEN 04 Screening of High Risk Patients of MRSA, CPE and Candida Auris for IPAC Surveillance

GEN05 Lidocaine for Initiating a Peripheral IV Cath

GEN 06 Anaphylactic Management

GEN 07 Renal Dose Adjustment

GEN 08 – R Hypoglycemia Management for Adults

GEN 09 – R Naloxone for Opioid Induced

GEN 10 IPAC Respiratory Virus Testing for Inpatients

GEN 11 Blood-Borne Pathogens Exposure - Source Patient Testing

RESP 01 Ordering Lab Tests and DI

RESP 03 Subcutaneous Injection of Lidocaine for Arterial Punctures

DIET 01 Ordering & Adjusting Enteral Tube Feeding by a Registered Dietician

DIET 02 Ordering & Adjusting Therapeutic Diet Orders

DIET 03 Ordering & Adjusting Parental Nutrition (PN)

SPEECH 01 Diet Texture & Feeding Care

PHARM 02 Smoking Cessation

PHARM 04 Pharmacist Adaption and Renewal Orders

PHARM 05 VTE Prophylaxis

WCH 08 – R Newborn Admission

WCH 09 – R Sucrose 24%

Family Medicine

ASP 01 Auto Consult ID for SAB and Candidemia - ASP

Hospitalist

ASP 01 Auto Consult ID for SAB and Candidemia - ASP

Anaesthesia

ANA 02 INR

ANA 03 MONITORING BY AA FOR GEN ANAESTHESIA

ANA 04 MONITORING BY AA FOR CONSCIOUS SEDATION, LOCAL OR REGIONAL ANAE.

ANA 05 REVISED CARDIAC RISK INDEX (RCRI) ASSESSMENT

ANA 07 Pre & Post-Operative Diabetes Management

ANA 08 – R Post Anaesthetic Care Unit - Adult

ASP 01 Auto Consult ID for SAB and Candidemia - ASP

CC 08 Aspiration Of Gastric Residuals Prior To OR

RESP 01 Ordering Lab Tests and DI

RESP 02 Lidocaine for Arterial & Venous Cannual Insertion

SX 06 Provision of Instructions regarding Medications by Preoperative clinic Registered Nurses

SX 07 Preoperative Diabetes

WCH 10 C-Section Pre-Op Medication

Critical Care

CC 01 Defibrillation

CC 02 Non-Invasive Transcutaneous Pacing

CC 03 Life Saving Drugs

CC 04 Ordering Lab Tests & DI

CC 05 CCRT Initial Assessment

CC 06 CCRT Chest Pain

CC 07 CCRT Suspected Sepsis

CC 08 Aspiration Of Gastric Residuals Prior To OR

CC 09 Sodium Citrate 4% Central Venous Access Device (CVAD) Locking Solution

RESP 01 Ordering Lab Tests and DI

RESP 02 Lidocaine for Arterial & Venous Cannual Insertion

SPEECH 02 Nasopharyngeal Endoscopic Examination

ASP 01 Auto Consult ID for SAB and Candidemia - ASP

Cardiology

CARDIO 01 Interrogation of Cardiac Devices and lead function

CARDIO 03 Intravenous Initiation

CARDIO 04 Cardiac registered nurses working within the cardiology/pacemaker clinic

CARDIO 05 Pre Procedures Diagnostics

ASP 01 Auto Consult ID for SAB and Candidemia - ASP

Emergency

ER 01 – R Medication for Adults

ER 02 – R Therapeutic Procedures for Adults

ER 03 – R Imaging For Adults

ER 04 – R Laboratory Tests and Diagnostic Procedures for Adults

ER 05 – R Asthmas- Adult Age 18 Years and Over

ER 06 – R Therapeutic Procedures, Medication & Laboratory Tests for Pediatric Patients

ER 07 – R Asthma Paediatric 1-18 Years of Age

RESP 02 Lidocaine for Arterial & Venous Cannual Insertion

Internal Medicine

RESP 01 Ordering Lab Tests and DI

RESP 02 Lidocaine for Arterial & Venous Cannual Insertion

ASP 01 Auto Consult ID for SAB and Candidemia - ASP

Midwives

WCH 01 Fetal Maternal Blood Screening

WCH 02 Prevention of Early Onset Neonatal GBS Disease

WCH 03 Midwives Assisting at C-Sections

WCH 08 –R Admission Process for all Newborns

WCH 09 – R Sucrose 24%

Nephrology

NEPH 02 Edetate (Kitelock) 4% Central Venous Cath Locking Solution

NEPH 03 Management of Chest Pain & Dyspnea

NEPH 04 MANAGEMENT OF INTRADIALTIC HYPOTENSION AND MUSCLE CRAMPING

NEPH 05 Management of Pain

NEPH 06 Management of Nausea, Vomiting and Dyspepsia

NEPH 07 Management of Non-Functioning Central Venous Catheter

NEPH 08 Local Anaesthesia for Vascular Access Cannulation

NEPH 09 Management of Diarrhea

NEPH 10 Management of Dialysate Potassium

NEPH 11 Renal Dietician Orders

NEPH 12 Management of Hypoglycemia in the Hemodialysis Unit

NEPH 13 Home Dialysis Program: Laboratory Assessment

NEPH 14 Renal Clinic Initial Assessment: Laboratory

NEPH 15 Renal Clinic Ongoing Laboratory Assessment

NEPH 16 Hemodialysis Anticoagulation

NEPH 17 Erythropoietin (EPO) & Iron Protocols

NEPH 18 Patient Transfer to KCC/Nephrology Clinic

NEPH 19 Post Renal Transplant Laboratory Assessment

NEPH 20 Renal Dietitian Diabetes Management

NEPH 22 Hemodialysis: Symptom Related Diagnostic Testing

ASP 01 Auto Consult ID for SAB and Candidemia - ASP

CC 09 Sodium Citrate 4% Central Venous Access Device (CVAD) Locking Solution

OB/GYN

WCH 01 Fetal Maternal Blood Screening

WCH 02 Prevention of Early Onset Neonatal GBS Disease

WCH 03 Midwives Assisting at C-Sections

WCH 07 - R Birthing Unit Triage

WCH 12 Antibiotic Prophylaxis Prior To C/Sections

SX 06 The Provision of Instructions regarding Medications by Preoperative clinic Registered Nurses

ASP 01 Auto Consult ID for SAB and Candidemia - ASP

Oncology

ADCP 01 Anaphylaxis/Hypersensitivity

ADCP 02 Laboratory Investigations for Patients Eligible to receive Daratumumab

ADCP 03 Speech Language Referral

ADCP 04 Chemo Oral Premedication

ADCP 05 Alteplase Administration

ADCP 06 Sequencing Chemo and Radiation Therapy Treatments

ADCP 07 Treatment of Hypomagnesemia

ADCP 08 Treatment of Hypokalaemia

ADCP 09 “new” Administration of Emla-Lidocaine for the Removal of SecurAcath Device

ASP 01 Auto Consult ID for SAB and Candidemia - ASP

Orthopaedics

BC 01 Perioperative Blood Conservation

SX 01 Electrosurgery as a Controlled Act for RNFAs

SX 06 The Provision of Instructions regarding Medications by Preoperative clinic Registered Nurses

SX 10 Arthroplasty Surgery Preoperative Pain Medications

NEJAC 01 Ordering X-Ray

ASP 01 Auto Consult ID for SAB and Candidemia - ASP

Paediatrics

WCH 08 - R Newborn Admission

WCH 06 Head Ultrasound for Premature Infants<32weeks Gestation

WCH 09 - R Sucrose 24%

WCH 11 - R Hypoglycemia Management in Pediatric Patients

WCH 13 Respiratory Syncytial Virus (RSV) Clinic

WCH 14 Respiratory Syncytial Virus (RSV) Newborn Immunization

RESP 01 Ordering Lab Tests and DI

Plastic Surgery

SX 10 Arthroplasty Surgery Preoperative Pain Medications

Psychiatry

MH 01 Blood work for Outpatient Psychiatry Medication Clinic

MH 02 Nicotine Replacement Therapy

MH 03 Acetaminophen and Ibuprofen

ASP 01 Auto Consult ID for SAB and Candidemia - ASP

Surgeons [All]

SX 01 Electro surgery as a Controlled Act for RNFAs

SX 06 The Provision of Instructions regarding Medications by Preoperative clinic Registered Nurses

SX 08 ERAS

BC 01 Perioperative Blood Conservation

CC 08 Aspiration Of Gastric Residuals Prior To OR

ASP 01 Auto Consult ID for SAB and Candidemia - ASP

Urology

BC 01 Perioperative Blood Conservation

ASP 01 Auto Consult ID for SAB and Candidemia - ASP

SX 09 Urology Clinic Procedures

Withdrawal Management - Safe Beds

WMS 02 Mild to Moderate Pain Changes

WMS 03 Nausea Vomiting Diarrhea Gastric Reflux Changes

WMS 04 NRT

WMS 05 Diabetes Management

WMS 06 Sleep Management

WMS 07 Prevention of Neurological complications in alcohol use disorder

Wound Clinic Physicians

FT 01 Use Of Therapeutic Ultrasound For Wound Management (Us)

FT 02 HVPC E STIM OR E STIM

Consent

Date

Name(Required)

First Last

Preferred Email(Required)

A copy of your application will be sent to your preferred email address to verify successful submission.

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Reappointment Application – Active Reciprocal