Affiliated Medical Staff applicants

Application process

Thank you for your interest in joining the YNHH Affiliated Medical Staff. In order to apply for affiliate membership and clinical privileges, you must complete and submit all of the materials as indicated below.  Please utilize the Applicant Checklist-AHP to guide you in this process and ensure that you have completed all required paperwork.

An application fee of $200 must be provided in order for processing of your application to begin. Please be sure to submit a check or money order along with your materials.

At this time, electronic submission is not available. You must, therefore, print out the forms and return them in hard copy. All materials should be returned to the following address:

Yale-New Haven Hospital
Department of Physician Services
20 York Street, Hunter 4
New Haven, CT 06510

Applications may be submitted via U.S. Postal Service, Federal Express or in person. The Department of Physician Services is located on the fourth floor of the Hunter Radiation Therapy Building. For specific directions, please call (203) 688-2615.

Upon receipt of your application, you will be notified of any omitted or outdated documents. The Department of Physician Services will initiate reference requests on your behalf to the individuals you identify in your application.

Tips for completing your application

The extent to which you provide complete and thorough information and submit all of the items required will assist the Department of Physician Services staff in processing your application expediently.

• Be sure to provide names of reference writers who are appropriate based on the Guidelines / Requirements for Reference Writers for affiliated staff.
• Notify your reference writers that you have listed them and encourage them to reply quickly to our inquiry when they receive it.
• Make sure there are no gaps in time on your application from the time of graduation from professional school to the present.
• Make sure the start and end dates you indicate on your application include both the month and year.
• Remember, it is your responsibility to ensure that appropriate documentation is provided in order to complete your application. The verification of information submitted and the investigation of credentials can be a lengthy process. If you assist the Department of Physician Services in obtaining the necessary information, the processing time can be shortened.

Items to be read

• Medical Staff Bylaws
• Medical Staff Rules and Regulations
• Guidelines/Requirements for Reference Writers
  
• Infection Control/Standard Precautions Reading Material
• HIPAA Privacy and Security Reading Material
• Information on Interpreter Services at YNHH
• Information on Immunization Documentation
• Reading materials for conscious sedation (if conscious sedation privileges are requested)
• Additional reference material for conscious sedation
• YNHH Policy on Medical Staff Health
• Policy Focused Professional Practice Evaluation
• Medical Staff Policy on Hand Hygiene and Contact Precautions
• Current members of the YNHH Medical Board and Credentials Committee

Items to return:

1. Complete, signed, dated application. Note: Training, employment and practice history must be completed on the application itself. Reference to an "enclosed C.V." will not be accepted. Please refer to "Guidelines/Requirements for Reference Writers" above when listing references on your application.
2. Non-refundable $200 Application Fee made payable to Yale-New Haven Hospital
3. Applicant checklist - AHP indicating the enclosed vs. "to follow" items
4. Complete Claim-Suit Report Form if you have answered "yes" to question #17 on the application
5. Written statement explaining your reasons for requesting privileges and what contributions you expect to make to the clinical and teaching missions of the hospital.
6. Appropriate Clinical Privilege Delineation request form.
7. PA and APRN applicants must submit a copy of the protocol agreement between themselves and their supervising or collaborating physician. Template forms are available to use as a guide:
   PA/Supervising physician protocol template form
   APRN/Collaborating physician protocol template form
   
8. Copy of graduate (or other applicable) school diploma
9. All current licenses, including Connecticut
10. Immunization Documentation Form including evidence of PPD within the past 12 months
11. Hepatitis B Vaccine Declination (as applicable)
12. Current DEA certificate** (as applicable)
13. Current Connecticut State Narcotics Certificate** (as applicable)
14. Current malpractice insurance facesheet (Not required for employees of YMG or Yale-New Haven Hospital)
15. Identity Verification
16. Copy of current ANCC, NCCPA, ACNM, AANA, JCAHPO, LCC-ST Certification (as applicable)
17. Copy of curriculum vitae
18. Completed Infection Control Test and Standard Precautions Attestation Sheet (a score of 80% is required to pass)
19. Completed HIPAA Test (a score of 80% is required to pass)
20. Medicare/CHAMPUS Declaration
21. Conscious Sedation Self-Test and Attestation and evidence of appropriate airway management training (if conscious sedation privileges are sought).
22. Statewide Emergency Credentialing Program Participation (Optional)

For your convenience, the following links are provided:

• Application for the Connecticut Controlled Substance Registration (This application should be submitted directly to the State of Connecticut)
• Drug Enforcement Agency website.

Clinical privilege delineation

Please select as appropriate based on your education.

Please note the following:

• If you request privileges to administer conscious sedation, please print out the Requirements for Conscious Sedation and Self-Test.

Last revised: Feb. 1, 2008 (dh)

Home page URL: http://www.ynhh.org

All information is intended for your general knowledge and is not a substitute for medical advice or treatment for specific medical conditions. You should seek prompt medical care for any specific health issues and consult your physician before starting a new fitness regimen.