In review of your file and/or application for medical staff membership
MAGNA SURGICAL CENTER 9831 S. Western Avenue Chicago, IL 60643 Phone: 773-445-9696 ext.226 Fax: 773-445-3682 In order to initiate your process for medical staff membership at Magna Surgical Center, we will need the following documents or information: *Appointment (Credentialing) *The Illinois State required forms that must be used may be found at the IDPH website; idph.state.il.us, “A-Z Topic List”, “Healthcare Credentialing”/enclosed Curriculum Vitae Copy of Diploma Residency Certificate/Diploma Current copy of Illinois License Current copy of Illinois Controlled Substance License Current copy of DEA License Current Professional Liability Certificate showing the following: Certificate holder - Magna Surgical Center 9831 S. Western Avenue-LL Chicago, IL 60643 Current Hospital appointment(s) with complete addresses Current copy of Hospital(s) Privileges Current copy of Board Certification (if applicable) Clinical Privileges Delineation for Magna Surgical Center (enclosed) Authorization to Release Information (enclosed) Three names of professional references - including complete addresses Valid Photo ID (Drivers License or Passport) Business Card Tuberculin Test Results (Yearly Requirement) OR Fire Safety Attestation & Test (2) (enclosed) Infection Control Attestation & Test (1) (enclosed) Other: _____________________________________________ Please return the above requested documents at your earliest convenience, so that we may continue the privileging process. Please do not hesitate to contact me if you have any questions or if I may be of any assistance. Thank you. Mi’Chelle L. Lipscomb, Assistant Administrator Southwestern Medical Center d.b.a. Magna Surgical Center, LLC 9831 S Western Ave., Chicago, Illinois 60643 Ph: (773) 445-9696 Fax: (773) 445-9590 Infection Control Training Attestation Form I ________________________________, attest that I have completed the following: (Please check) Read the Infection Control: Hand Hygiene training packet Completed the test questions for Hand Hygiene scoring 100% Test (1) mailed or faxed back with attestation form Printed Name Specialty Signature Date Please mail or fax this form within 30 days of receipt. Mail or fax back to: Mi’Chelle Lipscomb Credentialing Magna Surgical Center 9831 S. Western Avenue-Lower Level Chicago, IL 60643 Fax: 773-445-3682 / 773-445-9590 Southwestern Medical Center d.b.a. Magna Surgical Center, LLC 9831 S Western Ave., Chicago, Illinois 60643 Ph: (773) 445-9696 Fax: (773) 445-9590 OR Fire Safety Training Acknowledgement I ________________________________, attest that I have completed the following: (Please check) Read the OR Fire Safety Training booklet Can identify the location of the Fire Extinguishers and how to use Reviewed the facility’s floor plan and the steps to evacuate Completed the test questions for OR Fire Safety scoring 20/20 Completed the test questions for the Fire Extinguishers scoring 100% Both test mailed or faxed back with form Printed Name Specialty Signature Date Please mail or fax this form within 30 days of receipt. Mail or fax back to: Mi’Chelle Lipscomb Credentialing Magna Surgical Center 9831 S. Western Avenue-Lower Level Chicago, IL 60643 Fax: 773-445-3682 / 773-445-9590
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