Provider Annual Education

Required Annual Provider Education – Please review all of the documents below.

For Tomah Health providers with Sedation / Analgesia privileges:

Sedation/Analgesia Policy (PDF)

Required Annual Provider Education Form

"*" indicates required fields

I attest*

By checking this box, I attest that:*

I have received and read the provided Provider Resource Handbook 2023 Tomah Health.
I have received and read the provided Confidentiality and Security Policy and Agreement on the previous page. I agree to comply with all of the terms and conditions therein.
I have received and read the provided the Standards of Professional Behavior for Medical Staff document and I agree to comply with all of the terms and conditions therein.
I have received and read the provided document on Avoiding Medicare & Medicaid Fraud Waste and Abuse above.
I have received and read the provided 2023 Infection Prevention education document.
I have received and read the provided HIPAA and Working Remote Education and Requirements document.
I have received and read the provided Orientation of Credentialed Provider policy.
I have received and viewed the Annual Education presentation which includes education on the following:
1. Communication and Teamwork techniques for Optimizing Patient Outcomes
2. Diversity in Healthcare
3. Abuse and Neglect
4. Suicide Prevention
5. Workplace Violence
6. Harassment
7. MRI and Radiation Safety
8. Hazard Communication: Safety Data Sheets (SDS)
9. Bloodborne Pathogens and PPE
10. Blood Administration
11. Code Team, Carts, and AED
12. General Safety and Quality Concerns
I understand that the most current Medical Staff Bylaws, Rules, and Regulations can be found on the Medical Staff Reference page on HealthConnect.

Sedation Analgesia Policy

(check this box if you currently hold Moderate Sedation privileges)

I have reviewed and understand the information in Sedation/Analgesia Policy and the privileging criteria above.

Conflict of Interest Policy*

I have read the Conflict of Interest Policy above. I agree to comply with all of the terms and conditions therein.

Please check an option and disclose relationships if applicable:

I have no organizational relationships or other circumstances to disclose under Tomah Health's Conflict of Interest Policy as reviewed above.

I hereby disclose the following organizational relationships or circumstances for review by Tomah Health's Chief Executive Office and Board of Directors to determine whether I have any actual or potential Conflicts of Interest. Please enter your relationship/circumstances in the comment box below.

Conflict of Interest relationship or circumstances

Annual Education Submission

Signature*

I understand that typing my First and Last name in the fields below constitutes as my electronic signature.

Name*

First Last

Health System Affiliation & Specialty*

Email*