New Provider Applicant | Tomah Health

Please review all of the documents below.

Confidentiality and Security of Information Policy/Statement (PDF)

Conflict of Interest Policy/Disclosure Statement (PDF)

Please fill out the form below to verify that you have reviewed all of the New Provider Applicant information above.

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Step 1 of 4

Policy Agreement*

By checking this box, I attest that:

I have read Tomah Health’s Confidentiality and Security Policy and Agreement above, and I agree to comply with all of the terms and conditions therein;
I have read Tomah Health’s Conflict of Interest Policy.

Conflict of Interest Policy*

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.

Please check an option and disclose relationships if applicable

Conflict of Interest relationship or circumstances

Authorization and Release

Authorization and Release Agreement*

By checking this box, I am agreeing to the following

I understand and agree that I have the burden of producing adequate information for verification of my background, professional competence, training and experience, for medical staff or allied health professional staff appointment and/or clinical privileges, and for resolving any doubts about such qualifications.
I authorize Tomah Memorial Hospital/Tomah Health to consult with any third party who may have information bearing on my professional qualifications, clinical competence, character, mental or emotional stability, physical condition, ethics, behavior or any other matter bearing on my qualifications for appointment to the medical staff or allied health professional staff.
I extend absolute immunity to Tomah Memorial Hospital/Tomah Health, and release from any and all liability, for any actions, recommendations, reports, statements, communications, or disclosures involving me, which are made, taken or received by Tomah Memorial Hospital/Tomah Health, by applying for appointment and clinical privileges.
This authorization includes the right to contact supervising/collaborating physician/s for peer recommendation. I agree to appear for an interview, if requested.

Name and Phone number of three (3) supervising/collaborating –or– peer physicians:

Physician 01*

Physician 02*

Physician 03*

Credentialing Acknowledgement

Credentialing Agreement*

By checking this box, I am agreeing to the following

I acknowledge that acceptance of the application by Tomah Health does not constitute a contractual agreement for employment, membership, or granting of privileges.
I acknowledge that, as a member, I am required and pledge to provide continuous care for my patients.
I acknowledge that the burden of producing requested documentation to support my application for initial and ongoing eligibility for membership or participation is my responsibility.
I acknowledge that misstatements or omissions may constitute cause for denial or revocation of membership or appointment.

Consumer Report*

I consent and authorize Tomah Health to procure a consumer report, which may include (but is not limited to) the following information

Records and information related to criminal history or federal sanctions, including but not limited to convictions, deferred adjudication, probated sentences, warrants and other types of changes
Medicare and Medicaid sanctions
Social Security verifications
Motor vehicle records
Previous address information

Signature*

By checking this box, I understand that typing my name below constitutes as my signature.

Name*

First Last

Health System Affiliation & Specialty*

Email*