Download - Martina Diditright, MD: CV · Martina Diditright, MD: CV Martina Diditright, MD 1001 Garden Drive Healthy Town, Good State, USA Ph: 000-123-456 Fax: 111-222-333 Email: [email protected]

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Copyright ECRI Institute, 2013

Martina Diditright, MD: CV

Martina Did itright, MD

1001 Garden Drive

Healthy Town, Good State, USA

Ph: 000-123-456 Fax: 111-222-333

Email: mdid [email protected]

Education and Postgraduate Training:

7/ 1996-6/ 1999 Post Grad uate Training

Goodville Hosp ital, Greene City, Good State, USA;

Goodville Hosp ital Family Practice Group, Greene City, Good State, USA.

7/ 1992-6/ 1996 University Medical College, Small State, USA

9/ 1988-5/ 1992 Urbanville College, Commonwealth of Urbanville, USA. BA (Chemistry)

Board Certification: 1999 Family Medicine, 2009 recertification Family Medicine

2008 Emergency Medicine

Other Certifications: ACLS current (expires 12/ 31/ 2013)

Licensure: Good State, USA (license no. 991122, expires 12/ 31/ 2014)

Commonwealth of Urbanville (licensure no. 007008, expires 08/ 31/ 2015)

DEA AB12340 expires 7/ 31/ 16

Practice Experience:

03/ 2012-07/ 2013 Urbanville Hospital Family Practice Group (Urbanville, USA)

01/ 2011-12/ 2011 Wellness Hospital --- emergency department (Urbanville, USA)

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07/ 2002-12/ 2010 Did itright Family Practice, Good State, USA.

07/ 1999-05/ 2002 Goodville Family Medical Center (Goodville, Good State)

Honors/Awards: Urbanville Volunteer Award (2011, 2012) (established annual free community

Health Fair)

Publications: ‘‘Improving Preventive Care for Patients w ith Low-health Literacy’’ Journal of Competent

Care 2012 May

‘‘Your Child ren’s Health’’ [weekly health column in The Goodville Press] 2009, 2010

‘‘How to u tilize quality measures to keep your patients out of the ED’’ Journal of Family

Medicine 2009 Dec

‘‘Managing chronic conditions through EHR tracking’’ Journal of Family Medicine 2009

Mar

‘‘How a potential lawsuit really affects your physician ’’ Journal of Law 2008 Oct

.

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Martina Diditright, MD: Application Packet

WELCOME LETTER FOR APPLICANTS

08/ 08/ 2013

Dear Dr. Did itright,

Thank you for your interest in becoming part of (name of health center) clinical staff. Prior to beginning your

service with (name of health center) you must complete our credentialing process and be approved by our board

of d irectors. The credentialing process involves evaluating a practitioner’s eligibility and competency for clinical

privileges. Our credentialing policy app lies to physicians, mid -level providers, and any licensed independent

healthcare practitioner who provides services in the (name of health center). All qualified applicants w ill receive

an application for medical staff membership and / or clinical privileges. We will make every effort to process your

application in a timely and efficient manner.

Credentialing is a five-step process:

Step 1. Applicant will receive the initial applicant packet

Step 2. Applicant will return completed applications along with requested documents

Step 3. Application will be reviewed and processed by our credentialing specialist to make sure all infor mation is

complete and accurate

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Step 4. The completed and verified applicant packet will be forwarded to the medical d irector to be presented to

the board of d irectors for approval

Step 5-. The Applicant will be notified of the board of d irectors’ decision

The credentialing process can take up to 90 to 120 d ays to verify, review, and obtain final app roval. To expedite

the process, your application should be without blanks or missing requested documents; if anything is missing,

the process will be delayed and could mean forfeiture of your privileges.

If at any time you have questions please contact ou r credentialing specialist at (phone number) or set up a

meeting to come to (name of health center) and go over your application prior to submission. Our goal is to assist

you to get on staff quickly while ensuring that we are compliant w ith Joint Commission and other relevant

guidelines.

Sincerely,

April Showers, MD

Medical Director

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CREDENTIALING APPLICATION

Please type or print responses legibly and in ink. Please complete the form in its entirety and attach all required

documentation. Incomplete applications will be returned to you and may result in a delay in the credentialing

process.

Supplementary d ocuments that must be completed and submitted include the following:

Affiliation Certification Letter

Three (3) Peer Reference Forms

Request for d elineation of Privileges

Professional Liability Claims History Form

Continu ing Medical Education (CME) Form

Attestation Statement

Please also submit the following with your app lication:

Curriculum vitae (CV)

Copy of medical/ professional license registration certificate

Copy of medical board certification

Other certificates (BLS, ACLS, ATLS, PALS, APLS)

Current Drug Enforcement Administration (DEA) registration

Current Controlled Dangerous Substances (CDS) registration

Copies of d iplomas (undergraduate, post-graduate, medical school, residency, fellowship)

Proof of professional liability insurance (policy declaration s page or letter from insurer)

Copy of most recent hepatitis B, MMR, and flu vaccination and tuberculosis PPD test

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Copy of government-issued picture identification

National Provider Identification number (NPI)

I. Demographic Information

Applicant Name: __Martina Did itright, MD______________________ SSN:123456789___________________ Address/ City/ State/ Zip:__1001 Garden Drive Healthy Town, Good State, USA _____________________ Phone: _000-123-456_________________Email: ____md id [email protected] ______Fax: _111-222-333_____ Date of Birth: _01/ 01/ 1965___ Place of Birth: Apple, USA__________________________________________ Gender: Male x Female Are you a United States Citizen? x Yes No If not a United States citizen, please check applicable box below: Work Permit (attach notarized copy) Visa Visa Type and Number: _________________

II. Professional/Licensure Information

Primary Practice Specialty:__Family Medicine_________________________________________Board Certified? x Yes No

Certifying Board:__American Board Family Medicine (1999, 2009), Emergency Medicine (2008)_______________________________

Certificate Number:__123/456_________Year Certified:___1999/2008_________

Last Year Recertified:__2009__________Expires:___2019/2018______________

Secondary Practice Specialty:Emergency Medicine_______________________________________Board Certified? X Yes No

Certifying Board:________________________________________________________________________________

Certificate Number:_____3456______Year Certified:_______2008_____

Last Year Recertified:_____________Expires:___2018______________

If not board certified , are you board eligible? Yes No Application d ate:_____________________

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Do you have a current Drug Enforcement Administration (DEA) license? x Yes No

License Number:_AD12340_______________________________Date of Expiration:__7/ 31/ 2016_________

Do you have a current Controlled Dangerous Substances (CDS) license? x Yes No

License Number:___5678_____________________________Date of Expiration:__12/ 31/ 2013_____________

Are you licensed to practice medicine in the state of (name of state)? x Yes No

Good State, USA (license no. 991122, expires 12/ 31/ 2014; Commonwealth of Urbanville (licensure no. 007008,

expires 08/ 31/ 2015)

Other Certifications (BLS, ACLS, ATLS, PALS, APLS)

Certification Certifying Organization Date Certified Date Certification Expires

ACLS American Heart Association 7/1/2000 12/31/2013

BLS 1996,97,98,99

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Professional History

Current Employer Address

Position

Full Time?

Part Time?

(include number

of hours per

week)

Date of Hire

(Month, Year)

03/12

Employment End

Date

Urbanville

Hospital Family

Practice Group

700 Main Street

Urbanville

Staff physician Yes 01/01/2011 07/31/2013

Previous

Employers

Address Position

Full Time?

Part Time?

(include number

of hours per

week)

Date of Hire

(Month, Year)

Employment End

Date

Wellness Hospital

100 Well Street, Pumpkintown Emergency

Physician

NO 24 01/2011

12/2011

Diditright Family

Practice

320 Well Street, Pumpkintown Family Practice

(owner;

physician)

YES 60 07/2002 12/2010

Goodville Family

Medical Center

600 Medical Center Drive,

Urbanville

Staff Physician Yes 45 07/1999 05/2002

Trick or Treat

Family Practice

400 Pumpkin Street,

Urbanville

Staff Physician YES 45 07/1999 05/2002

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Please provide the following information:

Yes No

Have you ever practiced under another name? If yes, what name?_________________________________________ x

Do you currently provide healthcare services in the state of (name of state)? x

Are you presently practicing in your specialty? x

Do you currently have active staff privileges at an accredited hospital? x

III. Insurance

Please attach proof of professional liability insurance, such as a policy declarations page or letter from insurer.

Name of Insurance Carrier:___Risky Business, Inc._____________Dates of Coverage:__2002- present_____

Full Address: __100 Malpractice Lane, Justice, USA _______________________________________________

Name of Previous Carrier(s):__DeepPocket, Inc._______________Dates of Coverage:__1999-2002________

Full Address: __007 Bond Drive, Fastlane, USA __________________________________________________

Name of Previous Carrier(s):_______________________________Dates of Coverage:____________________

Full Address: _________________________________________________________________________________

Has an insurance carrier denied , cancelled , or refused to renew your insurance coverage? Yes x No

(If yes, p lease attach a separate sheet with an explanation)

Have you ever had any professional liability claims brought against you? x Yes No

(If yes, p lease complete ‘‘Professional Liability Claims History Form ’’)

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IV. Education

Preprofessional Education

Name of School Address (City, State, Zip Code) Subject

Major/Minor

Years Attended Graduation Date

(Month, Year)

Degree

Urbanville College

99 President Blvd

Urbanville, USA

Chemistry;

Psychology

1988-92 5/92 BA (Magna Cum

Laude)

Professional Education

Name of School Address (City, State, Zip Code) Years Attended Graduation Date

(Month, Year)

Degree

University Medical College

1111 Jonas Salk Avenue

Small State USA

1992-96 06/96 MD

Residency Training and Fellowships (Post Graduation from Professional School)

Name of Institution Address (City, State, Zip Code) Specialty PG Level Date Completed

(Month, Year)

Total Number of

Months in Position

Goodville Hospital 123 Louis Pasteur Drive

Good State, USA

Family

Medicine

1-3 June 1999 36

Goodville Hospital Family

Practice Group

9999 Helen Keller Street

Green City, Good State

Family

Medicine

3 June 1999 6

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Teaching/Research Appointments

Name of Institution Address (City, State, Zip Code) Position Dates of Appointment (From/To)

Visiting Staff Appointments

Name of Institution Address (City, State, Zip Code) Position Dates of Appointment (From/To)

Wellness Hospital

222 Well Blvd

Ban, USA

Active staff 2010-present

Urbanville Hospital

100 Street Road

Urbanville, USA

Active Staff 2010-present

Goodville Hospital

100 Good Road

Goodville, USA

Active Staff 1999-2010 (until moved)

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V. References

Please list three professional references who can attest to the candid ate’s qualifications, clinical and professional

competence, mental competence, and character. At least one reference must be an attend ing or supervising

physician. Each reference must also complete the ‘‘Applicant Peer Request Form ’’ and return to (name of health

center).

1. Name:__May Day, MD___________________________Title:___ Director, Dept. Emergency Medicine Wellness Hospital__

Relationship to Candidate:____Former Supervisor______________________ ____________________________________

Address:___007 Bond Street, Urbanville, USA _____________________________________________________________

Phone: 444-444-4444___________Fax:________________________Email:[email protected]______________________

2. Name:__Abrahim Linkon MD ____________________________Title:__Director, Urbanville Family Practice Group __________

Relationship to Candidate: Former Medical Supervisor _________________________________________________________

Address:___007 Bond Street, Urbanville, USA ______________________________________________________________

Phone:___222-222-222________Fax:________________________Email:[email protected]____________________

3. Name:____Henry Cleanhands, RN_________________________Title: Director of Nursing Urbanville Hospital______________

Relationship to Candidate:__Co-Chair of Committee for Interdisciplinary Best Practices in Primary Care __________________________

Address _____007 Bond St, Urbanvville USA______________________________________________________________

Phone:__333-333-3333__________Fax:______________________Email: [email protected]__________________

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VI. Disciplinary Information

Please attach a separate sheet with an explanation for any ‘‘yes’’ answers

Yes No

Has your medical license ever been revoked, restricted, or suspended? x

Have your clinical privileges ever been revoked, restricted, or suspended? x

Has your membership on any medical staff ever been revoked, restricted, or suspended? x

Has your DEA license ever been denied or suspended? x

Have you ever been excluded from participation with Medicare or Medicaid program? x

Have you ever been requested to appear before a licensing agency (State Board of Examiner’s, Drug Enforcement Agency) for any reason?

The father of a pediatric patient who filed a lawsuit against me and other also lodged a complaint against me with the state medical board.

x

Have you ever been sanctioned by a federal or state agency? x

Have you ever been convicted of a felony or misdemeanor other than a minor traffic offense? x

Have you ever discontinued your practice (other than for vacation, education/training, maternity leave, or leave due to illness) for three

months or more?

x

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VII. Health Fitness

Please attach a separate sheet with an explanation for any ‘‘yes’’ answers

Yes No

Do you presently have any physical or mental condition, including alcohol or drug abuse, that may affect your ability to perform clinical or

professional duties?

x

Are you currently taking any medications that may affect your ability to perform clinical or professional duties? x

Do you have any communicable diseases? x

_x__ Please initial to certify that you are in good health and have no physical or mental cond itions that may affect

your ability to perform clinical or profession al duties.

Most recent physical exam performed by: Henrietta Cleanhands, MD__________Date: __06/ 01/ 2012___

Results of examination:____within normal limits__________________________________________________

VIII. Other Information

Yes No

Do you speak any other language other the English? If so, which language(s)

Fluent in the language Elsewhere

_____________________

_____________________

x

Are you presently or planning to reside within commuting distance to the Health Center? x

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AFFILIATION CERTIFICATION LETTER

Martina Did itright, MD____________________________________ Family Medicine___________________ Name of Applicant Specialty

To Whom It May Concern:

I have submitted an app lication for appointment/ reappointment to the staff of (name of health center). Please

complete the information below and return it d irectly to the address below. My signature authorizes you to

complete the form at my request. Thank you for your prompt attention to this request.

Sincerely,

Martina Diditright, MD 8/15/2013

____________________________________________________________________________________

Release of information signature/ d ate

Current Status:

____________________________________________________________________________________

Membership from _____________(date) to ______________(date)

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Yes No N/A

Have the practitioner’s privileges been restricted, suspended, or revoked? x

Have the practitioner’s privileges been reduced? x

Has the practitioner attempted procedures beyond his or her skill or training? x

Has the practitioner been the subject of disciplinary action by your organization or licensing body? x

Have the practitioner’s professional morbidity, mortality, infection, or complication rate exceeded your organization’s criteria for the

standard of practice?

x

Has the practitioner been suspended for medical record violations since the last appointment or reappointment? If yes, how many

times?___________

x

Has the practitioner’s behavior been disruptive to patient care? x

Have there been any written complaints about practitioner by patients, employees, or medical staff members? x

Has the practitioner been involved in a malpractice claim or lawsuit since the last appointment or reappointment? x

Is the practitioner compliant with organizational policies and medical staff bylaws? x

Does the practitioner have any physical, mental, emotional, or drug or alcohol dependence problems that may interfere with his or her

ability to perform professional and staff duties?

x

At the appropriate time, will you likely reappoint the practitioner to your medical staff?

Verification provided by:

Name:____Mary Poppins _________________________________________________

Signature:____Mary Poppins_________________________________________________

Date:____8/ 30/ 2013______________________________________________________

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Phone:____777-777-777____________________________________________________

Title:_____Credentials Coord inator_________________________________________

Fax:________________________________________________________

Institution Name:____Urbanville Hosp ital_________________________________________

Return Form to: Health Center, Address, City, State, ZIP phone # fax #

APPLICANT PEER REFERENCE FORM

Three (3) references are required for all applicants for appointment / reappointment.

Name of Applicant: Martina Did itright, MD

Specialty: Family Medicine

To Whom It May Concern:

I have submitted an app lication for appointment/ reappointment to the staff of the (name of health center). Please

complete the information below and return it d irectly to the address below. My signature authorizes you to

complete the form at my request. Thank you for your prompt attention to this request.

Sincerely,

__Martina Diditright, MD, 8/15/2013_________________________________________

Signature/ d ate

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Yes No

Does the practitioner demonstrate current clinical competence and provide appropriate care to patients? x

Does the practitioner demonstrate good diagnostic capabilities and good technical skills in the performance of invasive

procedures, if applicable?

x

Does the practitioner demonstrate effective communication skills with patients, families, and others involved in their care? x

To the best of your knowledge, does the practitioner have the appropriate mental and physical health to perform patient care

duties?

x

Have you observed or been informed of any physical or behavioral condition, including alcohol or drug dependence, related to

this applicant that has or reasonably may affect his or her ability to perform professional duties?

x

Does the practitioner maintain timely documentation of history and physical exams, progress notes, operative notes, narrative

summaries, etc.?

x

Does the practitioner make hospital rounds on a daily basis or as otherwise required and readily answer calls and consultations

when requested?

x

Does the practitioner exhibit personal integrity and adherence to professional ethics? x

Does the practitioner work well with others, communicate well with other providers, and have a good rapport with patients? x

What is your opinion regarding competency in performing the attached privileges? x

Are you aware of the practitioner being subjected to any disciplinary action by any licensing or certifying board or any

healthcare facility regarding medical staff membership and/or clinic privilege?

x

The above evaluation is based on (check all that apply):

Close observation of clinical performance xGeneral Impression Composite information from file Practitioner’s repu tation in the community Co-worker

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Recommendation:

xHighly recommend without reservation Recommend as qualified and competent Recommend with reservation Do not recommend

Signature:_______Donald Duck ____________________________________

Date:____09/ 02/ 2013_____________________________________________

Phone:____555-666-7777___________________________________________

Print Name:_Donald Duck, MD_____________________________________

Title:_____Emergency Physician_____________________________________

Fax:______________________________________________________________

Return Form to: Health Center, Address, City, State, ZIP phone # fax #

DELINEATION OF PRIVILEGES

Name of Applicant:___Martina Did itright, MD__________________________Specialty:_Family Medicine

Core Privileges1

Approved Proctoring

Required

Denied

Admit, evaluate, diagnose, treat, and provide consultation to

patients of all ages, with a wide variety of illnesses, diseases,

injuries, and functional disorders of the circulatory, respiratory,

endocrine, metabolic, musculoskeletal, hematopoietic,

gastroenteric, integumentary, nervous, female reproductive, and

genitourinary systems. May provide care to patients in the

intensive care setting in conformance with unit policies. Assess,

stabilize, and determine disposition of patients with emergent

conditions consistent with medical staff policy regarding

emergency and consultative call services.

x

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List Additional Procedures2 Approved Proctoring

Required

Denied

Applicant’s Signature/ Date:___ Martina Diditright, 8/15/2013___________________________________

Specialty Consultant Signature/ Date :___________________________________________(if applicable)

Medical Director Signature/ Date: __________________________________________________________

Medical Advisory Board Signature/ Date:____________________________________________________

Representative for Credentialing or Board Committee Signature/ Date:

Notes:

1. The American Academy of Family Physicians (AAFP) defines Core or Category I privileges as ‘‘uncomplicated ,

basic procedures and cognitive skills.’’ AAFP adds: ‘‘Physicians assigned to this category will be graduates of

approved medical/ osteopathic schools who are properly licensed and have demonstrated skills in family

medicine. Each request for privileges will be considered on an ind ividual basis and will require approval and

supportive documentation.’’ The health center should define Core or Category I privileges and skills necessary to

be granted these privileges.

2. Additional procedures, d efined by AAFP as Category II and Category III, are of increasing complexity and may

require add itional specific training, education, experience, and / or board certification as defined by the health

center. The health center should list each procedure that it w ill grant privileges for and the specific

documentation required of physicians to demonstrate that they meet privileging requirements.

For more information, see AAFP’s ‘‘Ambulatory Privilege Delineation Form for Family Physicians’’ at

http:/ / www.aafp.org/ online/ en/ home/ practicemgt/ privileges/ misc/ ambprivilege.html .

http://www.aafp.org/online/en/home/practicemgt/privileges/misc/ambprivilege.html

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PROFESSIONAL LIABILITY CLAIMS HISTORY FORM

The following is necessary to complete the credentialing verification process and will be kept confidential. Please

print or type answers to the following for any professional liability claims and lawsuits reported to your

professional liability insurance carrier, open or closed , settled or paid . Include only one case per sheet; copy this

form if needed for more than one case.

Provider Name:___Martina Did itright, MD_______________________________________________________

1. Plaintiff Name: Johnny B Goodenough Sr., representative of Johnny B. Goodenough Jr., a minor _______

Date of Birth:___________________________________ Age:___11_______

Name of patient involved :___Johnny B. Goodenough Jr .____________________________________________

Month and year of occurrence:___May 2000___________(event precipitating claim)

Month and year of claim or lawsuit:__May 2006________________________________

Insurance carrier time of claim:____Deep Pocket, Inc. _________________________________

2. What is/ was your status: Primary defendant x Co-defendant Other

Explain and list other defendants:

Defendants: Martina Did itright, MD; Jack Olantern, MD

I saw the patient in the office setting. The patient subsequently underwent surgery by Dr. Surgeon at Pumpkin

Hospital._______________________________________________________________________ =

What was the patient’s outcome?

Patient lost testicle. ___________________________________________________________________________

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Provide a summary of the allegations made against you.

The complaint stated ‘‘Alleged failure to timely d iagnose testicular torsion and refer minor plaintiff to hosp ital

emergency department or surgeon.’’____________________________________________________

What was your clinical role with regard to the patient?

I assessed the minor patient in the office setting for complaint of scrotal pain. The child ’s father d id not follow

my recommendation and instruction for immediate assessment in the hosp ital emergency department. But I d id

not document the recommendation in the patient’s record clearly to reflect the d ischarge instructions that I gave

to the child ’s father. Surgery performed by Dr. Surgeon was not successful. I believe that the verd ict was based

on sympathy for the child .

Current Status of Claim: (please check one)

Still pending as of d ate:_______________________

Name and address of your defense attorneys: Defense at Any Price Law Firm; Billy Hours, Esq.

Has a trial date been set? Yes No Trial Date __June ______________________

Settled out of court before trial? xYes No

Amount of settlement on your behalf $__100,000_(Dr. Surgeon also contributed to the settlement in amount

unknown to me)_________

Current status of lawsuit:

Dismissed : Date:_______________________

Defense Verd ict Date:_______________________

Plaintiff Verd ict Date:_______________________

Judgment Amount $:__________________________ Date:___________________

Amount of total judgment paid on your behalf $____100,000_____________________________

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This professional liability claim information form is required on all claims/ lawsuits that are reported by your

professional liability insurance carrier and / or the Nat ional Practitioner Data Bank. Clinical details are required

for all suits, regard less of status of settlement amount.

I certify that the information contained in this form is correct and complete to the best of my knowledge.

___Martina Diditright, MD_______________________________________________

Applicant’s Signature

Martina Did itright, MD_______________________________________________ Print Name __8/ 15/ 2013_________________

Date

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CONTINUING MEDICAL EDUCATION (CME) FORM

Please use this form to list current continuing medical education (CME) cred its earned within the last two years.

(name of health center) requires (number) of CME cred its. This form can be used in lieu of send ing copies of your

CME certificate(s). Please make as many copies of this page as needed .

Course Title Date Facility Address # CME

1. Using your EHR to improve patient care 07/2013 Ace Hospital 2

2. Utilizing Clinical Decision Support Tools

to Enhance Your Outcomes

05/2013 ABC 4

3. Family Medicine review

4. Cardiology

5. Medical record documentation and the

electronic medical record

07/2012

Cinamonville Hospital

12

9

3

6. Pediatric emergency care 06/2010 HealthyKids Hospital, USA 12

7. Challenges in the Care of the Diabetic

Patient

06/2008 Cinnamonville Hospital 9

8. Assessing Musculoskeletal Injuries 06/2007 Cinnamonville Hospital 4

9. Mental Health Disorders 06/2006 Mental Health Association of

Cinnamonville

3

10. Current Geriatrics 06/2005 Medical Society of

Cinnamonville

9

11. Dermatology Review 06/2004 Pumpkin Hospital 3

12. Gastroenterology Review 06/2003 GI Society of America 6

13. Legal Issues in Emergency Medicine 06/2002 Pumpkin Hospital 2

14.

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15.

16.

17.

18.

19.

20.

21.

22.

23.

I, ___Martina Did itright, MD__________________________ (print full name of the physician/ practitioner), agree,

as evidenced by my signature, that the information provided in this CME form is true and complete to the best of

my knowledge and that the omission or falsification of information may be cause of ineligibility or terminatio n

from medical staff membership

Applicant Signature:______Martina Diditright MD _________________________

Date:___08/ 15/ 2013_________________

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ATTESTATION STATEMENT

I, ____Martina Did itright, MD_________________________ (print full name of the physician/ practitioner), agree

as evidenced by my signature that the information provided in this application is true and complete to the best of

my knowledge and that the omission or falsification of information may be cause of ineligibility or terminatio n

from medical staff membership. I further agree that I have current professional liability coverage and I have

d isclosed the history of loss or limitation of privileges or d isciplinary action.

____ Martina Diditright MD ___________________8/15/2013_________________________

Applicant Signature Date

Martina Did itright, MD _________________________________________________________________ Print Name

All policies, procedures, and forms reprinted are intended not as models, but rather as samples submitted by ECRI Institute member and nonmember

institutions for illustration purposes only. ECRI Institute is not responsible for the content of any reprinted materials. Healthcare laws, standards, and

requirements change at a rapid pace, and thus, the sample policies may not meet current requirements. ECRI Institute urges all members to consult with

their legal counsel regarding the adequacy of policies, procedures, and forms.

Download - Martina Diditright, MD: CV · Martina Diditright, MD: CV Martina Diditright, MD 1001 Garden Drive Healthy Town, Good State, USA Ph: 000-123-456 Fax: 111-222-333 Email: [email protected]

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