MEDICAL AFFAIRS OFFICE
310 East 14th Street
South Building-Basement, Suite B07
New York, New York 10003
Phone: (212) 979-4661 / 4664 / 4305
Fax: (212) 353-5950
Email: medaffairs@nyee.edu

PLEASE READ THIS PAGE CAREFULLY!!

The Reappointment Application for the Professional Staff and Allied Health Professional Staff whose cycle will be ending May 31, 2013 will be available from December 10, 2012 to February 15, 2013. Applications received or completed after February 15, 2013, will incur a late fee of $500.00.

NO APPLICATIONS WILL BE ACCEPTED AFTER MARCH 1ST!

IN ADDITION to the Reappointment Application and Data Review, current copies of the following documents must be submitted to the Medical Affairs Office via scan/email, mail, and/or fax:

• Consent and Release from Liability – Download and print
• Medical Health Status Evaluation –Download and print
• Medicare Acknowledgement –Download and print
• Authorization to Obtain Malpractice Claims History –Download and print
• Updated current Curriculum Vitae (must include MONTH and YEAR)
• A clearly identifiable Government-issued photo ID (i.e. Driver’s License, Passport)
• A copy of your current Malpractice Insurance certificate of insurance naming New York Eye and Ear Infirmary as Certificate Holder:
• Primary Insurance of $1,300,000 / $3,900,000
• Excess Insurance of $1,000,000 / $3,000,000

Please note that we do not need the Declarations Page or Binder. It must say “CERTIFICATE OF INSURANCE.” If you do not have it, then you must call your malpractice carrier and have them send one to us.

• Copy of your current New York State License and Registration
• Copy(ies) of current out-of-state medical licenses and registrations
• Copy of your DEA License Registration with New York State address
• Current Infection Control certificate
• Proof of Board Certification and/or Re-certification
• Copies of CME Credit Certificates (50 Category 1 credits for the period 2011-2012).
• ACLS/PALS certification for Anesthesiology Department
• Non-refundable reappointment fee of $400.00 made payable to NYEEI (Does NOT apply to Allied Health Professionals, Consultants, and Affiliate Staff).

Reminder: Reappointment to the Professional Staff at the Infirmary is contingent on the following NYEEI centered activities but not limited to:

• Use of Clinical Privileges granted
• Number of surgeries as a primary surgeon
• Number of surgeries as assisting surgeon
• Laser usage (private or service cases)
• Patient admissions
• Clinical attendance and participation
• Teaching of surgery with Residents
• Clinic and inpatient consultations
• On-call (especially Metropolitan Eye Trauma Service)
• Participation in departmental meetings
• Educational/academic endeavors

Please note that your application will NOT BE PROCESSED if you are on suspension for delinquent Medical Records.

The Reappointment Application is available for submission in two formats:

• Electronic submission with signature (Click here to view the instructions on how to sign electronically)
• Signed and sent to the Medical Affairs Office by mail, fax or scan (along with the supporting documents)

Your reappointment application will not be complete until ALL supporting documents are submitted from the above checklist. A late fee of $500 will be assessed if any items are missing.

You will be able to review, and correct as needed, the information currently in your file.

IMPORTANT: Your computer must have Adobe Acrobat Reader version 8 or higher to access and electronically sign forms. Download Adobe Acrobat for free, here: http://get.adobe.com/reader/

Notice to Mac Users: By default, Mac computers will try and open the electronic forms in Apple Preview. You will need to first save the file, launch the free Acrobat Reader and then open the file.

Please call the NYEEI Information Systems Help Desk at (212) 979-4273 if you have any technical difficulties.

FINALLY – you must complete PART A and PART B (Data Review and Reappointment Application) (Click here to view the illustrated instructions)

Contact Information

Medical Affairs Office
The New York Eye and Ear Infirmary
310 E. 14th Street
New York, NY 10003
medaffairs@nyee.edu
(212) 979-4305/4664/4661 TEL
(212) 353-5950 FAX

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