Form 08-4109h - Hospital Privileges Information October 1999 printable pdf download

Form 08-4109h - Hospital Privileges Information October 1999

DPM

STATE OF ALASKA

FOR OFFICE USE ONLY

DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT

DIVISION OF OCCUPATIONAL LICENSING

STATE MEDICAL BOARD

P.O. BOX 110806

JUNEAU, ALASKA 99811-0806

(907) 465-2541

E-mail: license@dced.state.ak.us

HOSPITAL PRIVILEGES INFORMATION

I am applying for a license to practice podiatry in the State of Alaska. The State Medical Board requires that this form be

completed by each hospital where I have held privileges during the last five years. Please complete this form and return it

directly to the State Medical Board at the above address.

Name:

Date of Birth:

Address:

Social Security Number:

Name and Address of Hospital:

(Below to be completed by Hospital Staff only)

Dates of Hospital Privileges:

o Yes

o No

Has there been any disciplinary action against this physician?

o Yes

o No

Is there any derogatory information on file?

o Yes

o No

Is there any reason you would not readmit this physician to your medical staff?

If the answer to any one of these questions is “Yes,” please attach explanation.

Hospital Name:

Mailing Address:

City, State, Zip Code:

Signature

Title

Date

08-4109h (Rev. 10/99)

Form 08-4109h - Hospital Privileges Information October 1999