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