Medical Dental Staff (MDS) Forms

Annual Health Assessment  Revised February 2, 2015
To be completed by your personal physician and submitted to the Medical Staff Office (MSO) every year. RGH MDS does not require that your physician complete a physical, but complete this form attesting to your physical and mental ability. It is up to your physician to decide if he/she will complete the form without a physical. RGH MSO will also accept the Employee Health Service (EHS) form for those who are employed by RGHS.

Authorization & Release Form
This is necessary as part of the appointment and reappointment process. Sign, date and return to the Medical Staff Office when requested.

Deep Sedation – Dentistry and Emergency Medicine Added September 8, 2016
To be considered for the performance of Deep Sedation you must be approved for Moderate Sedation, read all Deep Sedation policy and procedure documents, sign the Deep Sedation by Non-Anesthesiologist Attestation Form, provide certification in ACLS, ATLS, PALS, or NRP (unless board certified in Emergency Medicine) and send your request to the RGH Medical Staff Office for processing. You will be notified of the review outcome.

Deep Sedation Attestation Added September 8, 2016
Send this along with the supporting documents to the RGH Medical Staff Office

Infection Control Manual
Infection Control Certification is required every four years by New York State to maintain your state licensure. Review this manual and complete the Infection Control Test when requested by the Medical Staff Office.

Infection Control Test
When you have reviewed the manual, please complete this test, sign, date and return to the Medical Staff Office. If you pass the test, a certificate will be sent to you at your primary office address location within one week. The Medical Staff Office will retain a copy. Be sure to send a copy of your certificate to any other healthcare facilities where you may be a member.

Initial Health Assessment  Revised February 2, 2015
Required for all new applicants to the RGH Medical & Dental Staff. Return to the Medical Staff Office.

Medicare Release & Assignment Form

To be signed and dated by all new applicants to the RGH MDS. Return to the Medical Staff Office

Required by Medicaid – The patients signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the provider of service or supplier when the provider of service or supplier accepts assignment on the claim.

The patient or authorized representative must sign and enter either a 6-digit date. (MM/DD/YY, 8-digit date (MM/DD/YYYY), or an alphanumeric date (January 1, 1998) unless the signature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in the provider, physician, or supplier file in accordance with Medicare Carriers Manual (MCM) 3047.1-3047.3. If the patient is physically or mentally unable to sign, a representative specified in MCM 3008 may sign on the patient’s behalf. In this event, the statement’s signature line must indicate the patient’s name followed by “by” the representative’s name, address relationship to the patient and the reason the patient cannot sign. The Authorization is effective indefinitely, unless the patient or the patient’s representative revokes this arrangement.

Signature by Mark (X). When the illiterate or physically handicapped enrollee signs by mark, a witness must enter his/her name and address next to the mark.

Moderate Sedation Test  Added August 10, 2011
To perform Moderate Sedation you must provide this test along with copies of certification in ACLS, BLS or Airway Management Skills. If you plan on performing Pediatric Moderate Sedation on children 12 years and under you must also provide PALS documentation.

NP Practice Agreement
Required for all Nurse Practitioners working at RGH licensed facilities. This must be updated by you when there are any changes. A copy must be sent to the Medical Staff Office.

NP Form 4 – Verification of Experience  Updated April 26, 2013

NP Quarterly Review  Revised June 26, 2016
RGH Nurse Practitioners are required to be reviewed by their collaborating physician on a quarterly basis.  A copy of this form, signed and dated by the collaborating physician, must be submitted to the Medical Staff Office on a quarterly basis.

NYS Nurse Practitioner Requirements for Protocol Text  Updated August 13, 2014
All Nurse Practitioners are required to identify a protocol text, from the approved list, as your official practice protocol which must reflect the specialty area of practice as identified on your State Education Department issued nurse practitioner certificate. The approved protocol texts include provisions for case management, diagnosis and treatment of pathology in the specialty area. Additional protocols or textbooks which may be appropriate to the practice and/or employment setting may be used but need not be reflected in the collaborative agreement.

Questions about collaborative agreements and practice protocols may be referred to the State Board for Nursing by e-mailing, calling 518-474-3817 ext. 120 or by faxing 518-474-3706.

Procedure Change Form from Direct to General Supervision for NPs and PAs 
Use form to request change in privileges from direct to general supervision for nurse practitioners and physician assistants.

Reappointment Questionnaire
Must be completed by each RGH Medical & Dental Staff Member at time of reappointment. Send a completed copy to the Medical Staff Office.