CLICK ON THE BELOW THREE LINKS IN ORDER TO DOWNLOAD AND PRINT.  THEY MUST BE COMPLETED AND MAILED TO THE MEDICAL AFFAIRS OFFICE SEPARATELY.

• Signed Consent to Release from Liability – to be mailed or faxed to Medical Affairs Office.  Please note that we cannot process your application without this form.

• The Medical Health Status Evaluation – To be completed by a physician who is NOT a first degree relative, spouse, significant other or business partner.  You must download and print this form and return with your application or mail it separately after your physical exam, but prior to February 16, 2012.  PLEASE DO NOT DELAY SCHEDULING AN APPOINTMENT FOR A MEDICAL EVALUATION.

• Medicare Acknowledgement Form - to be mailed or faxed to Medical Affairs Office.  Please note that we cannot process your application without this form

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CURRENT COPIES OF THE BELOW DOCUMENTS MUST ALSO BE SENT TO THE MEDICAL AFFAIRS OFFICE VIA FAX, MAIL, OR EMAIL:

• Updated current Curriculum Vitae (must include MONTH and YEAR)
• A clearly identifiable Government-issued photo ID (i.e. Driver’s License, Passport Photo, etc…)
• A copy of your current Malpractice Insurance certificates (Primary must name New York Eye and Ear Infirmary as Certificate Holder.  The coverage limits must be as follows:

• Primary Insurance of $1,300,000 / $3,900,000
• Excess Insurance of $1,000,000 / $3,000,000

• Copy of your current New York State License and Registration
• Copy of other current 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 2010 to 2011).
• ACLS certification for Anesthesiology Department
• PALS certification for Anesthesiology Department
• Non-refundable re-appointment fee of $400.00 made payable to NYEEI.
• Delineation of Privileges forms (if required) can be downloaded from this website.

Please be reminded that your re-appointment will be delayed if the following item is delinquent:

• Completion of Medical Records

**The Medical Board has approved a late fee of $500.00 to be imposed without exception on applicants whose re-appointment materials are not received completed by the due date.  This policy will be strictly enforced.

• 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

• Electronic submission with signature
• Signed and mailed to the Medical Affairs Office

Your re-appointment application is not completed until ALL supporting documents are submitted from the re-appointment checklist.

You will be able to review, and correct as needed, the information currently in your file.  (Your computer must have Adobe Acrobat Reader version 8 or higher to access forms).