Medical Staff Services

UT Physician Application

DRAFT

Base Requirements For Medical Staff Membership:

1. Appointment to the faculty of The University of Toledo, College of Medicine
2. Current valid Ohio medical license
3. Professional liability insurance coverage*
4. Must be board certified, or board qualified and become board certified within five years of becoming board qualified.

Answer all questions completely and accurately. Reference to curriculum vitae, or other informational resource, cannot be accepted.

IMPORTANT NOTICE The application will be considered incomplete and unable to be processed if items are unanswered or attachments or explanations are missing.

Application Packet Contents: Acknowledgement and Authorization Application for Appointment Section 9: Claims Data (Malpractice Claims History Attachment) Section 11: Professional Liability Insurance Coverage (Malpractic Claims History Confidentiality Agreement, Authorization, and Release Form for Detailed Claim History Attachment) Applicants/Employees of the University of Toledo Physicians or The University of Toledo are insured through The University of Toledo Professional Liability Insurance Program and MUST complete the requirements of Section 11.A in order to complete application for professional liability insurance. Conditions of Appointment Professional Liability Insurance Application Practice Location Fact Sheet Insurance Attestation and Agreement Medicare Penalty Statement Pharmacy Letter (if applicable) Delineation of Priveleges form(s)

Submit the following documentation with the application: Recent curriculum vitae Photocopy of Ohio medical license Photocopy of recent government issued, wallet-size photo of applicant (e.g., driver?s license) Photocopy of current DEA certificate Photocopy of DEA certificate with Ohio address as soon as available Photocopies of the following educational/training certificates MD/DO/Dental degree Internship(s) Residency(s) Fellowship(s) Board certification(s) CPR certification Photocopy of visa or official documentation of current visa status if you are not a U.S. citizen Photocopy of ECFMG certificate (foreign medical graduates only) Photocopy of professional liability insurance certificate Signed Conditions of Appointment form

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*Professional liability insurance coverage of at least $1 million per claim and $3 million per annual aggregate. The insurance company through which it is purchased must be licensed to do business in Ohio and have an A.M. Best Company rating of at least A-, and a financial size of at least VII or be a self-insured retention fund that can attest that it has been reviewed by an actuary and has been deemed to be adequately funded.