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SQE-MST-002 1 of 16
MEDICAL STAFF APPLICATION CHECKLIST Thank you for requesting an application for medical staff membership andor clinical
privileges at American University of Beirut Medical Center All forms must be completed and
returned with the application The Application should be printed and returned to our office
with the Privilege Sheet and with your original signatures
Application
( ) One Completed and signed Application Form
( ) One updated Curriculum Vitae
( ) one form of identification that includes your name picture and signature (ie passport
copy) or Lebanese Identification Card) plus a wallet size current photograph
( ) List of CMErsquos for past two (2) years (Current CME not required if you have completed
residency or fellowship training or obtained board certification within the last two years)
( ) Completed and signed Clinical Privilege Form(s)
( ) Code of Ethics (to be retained by physician)
( ) Guidelines on Conflict of Interest
Insurance
( ) List of all previous Professional Liability Insurance Verification with claims filed settled or
pending)
LicensesCertification
( ) Copy of current Lebanese Order of Physicians registration
( ) Copy of Lebanese Ministry of Public Health license to practice Medicine or in a
specialtysub-specialty
( ) Copy of all previous Medical Licenses held in other countries
( ) Copy of National Social Security Fund participation registration
( ) Copy of Board Certification(s)
( ) Copy of BLSACLSPALSATLS current certification (if required)
Other Signatures
( ) Confidentiality of Information Statement
( ) Attestation Acknowledgement and Release form
( ) Disclosure of Conflict of Interest form
Documents required from applicant
( ) Copy of Medical Degree
( ) Copy of Residency(s) training certificate
( ) Copy of Fellowship(s) training certificate
( ) Letters of Recommendation (at least two letters should be provided from physicians who
are familiar with the applicantrsquos clinical practice(One letter should be from the
Chairperson or Chief of division of the last position that the applicant held and the other
letter should be from the program director of the Residency or Fellowship training)
Appendix 61 SQE-MST-002
SQE-MST-002 2 of 16
Application for Initial Appointment to the Medical Staff
TO Chairperson Department of ________________________________________
I wish to apply for appointment to
the
First Middle Last following category
___ Active ___ with admitting
___ Associate Medical Staff Membership ___ with consultation privileges to
AUBMC
___ Emeritus ___ without admitting
___ Honorary
Period of Faculty Appointment __________________________
The following are attached
Request of Clinical Privileges for the Specialty of _______________ Subspecialty of ____________
(if applicable)
A signed form for Disclosure of Activities which may involve Conflict of Interest
_____________________________________________
___________________________________
Applicant Signature Date
Chairpersons Recommendation
I agree with this applicantrsquos statement of health status
I recommend appointment to the following Category
___ Active ___ with admitting
___ Associate Medical Staff Membership ___ with consultation privileges to
AUBMC
___ Emeritus ___ without admitting
___ Honorary
I concur with the attached Clinical Privileges as requested on the form
I do not concur with the requested Privileges The reason(s) for changes have been discussed with
the applicant on _________________ and heshe understood and accepted (See changes on the
form)
I do not recommend appointment for the following reason(s)
___________________________________________________________________________________
_____________________________________ ______________
Chairperson Signature Date
Medical Board Action Date of Action________________________________
Approved as requested Approved with modification Not approved
Chief of Staff ____________________________________________ Date signed
________________________________ Signature
Appendix 62
SQE-MST-002
SQE-MST-002 3 of 16
Curriculum Vitae for Initial Appointment to the Medical
Staff
PERSONAL DATA
Full Name First Middle Last
Specialty
Subspecialty
Date of Birth
Day Month Year
Place of Birth
Residence Address
Street
City
Phone Cell Phone
Office Address
Street
City
Phone
EDUCATION (please include in CV)
Undergraduate
Graduate
Postgraduate Training
LICENSURE AND CERTIFICATION
Lebanese Licensure
Date of Lebanese Ministry of Health Licensure License No
Lebanese Order of Physicians registration number
Issue DateEnd Date
Has your License to practice Medicine in Lebanon ever been under any kind of investigation 1048576 Yes 1048576No
If yes please complete the following details
1- Date of Investigation Type of Investigation
Result of Investigation
2- Date of Investigation Type of Investigation
Result of Investigation
National Social Security Fund participation number Issue Date
Other Licenses
1- CountryState Status Issue DateEnd Date
Picture
Appendix 63
SQE-MST-002
SQE-MST-002 4 of 16
2- CountryState StatusIssue DateEnd Date
3- CountryState StatusIssue DateEnd Date
4- CountryState StatusIssue DateEnd Date
5- CountryState Status Issue DateEnd Date
SPECIALTY BOARD CERTIFICATION(S) (please include in CV)
APPOINTMENTS (please include in CV)
Hospital Appointments
Academic Appointments
SCIENTIFIC AND MEDICAL SOCEITY MEMBERSHIPS
Please include in CV
CARDIOPULMONARY RESUSCITATION (CPR) TRAINING ( as per the policy ldquoResuscitative training
3rd Edition SQE ndashMUL -001rdquo
Yes No
I have completed training in BLSACLS copy of certificate is attached
I am not trained in CPR but I am willing to enroll in training and I will
send a copy of certificate upon completion
I am unable to qualify for BLSACLS for the following reasons
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
PREVIOUS AND CURRENT PROFESSIONAL LIABILITY INSURANCE
1- Name of Professional Liability Insurance Company helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Policy Number helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Amount of Coverage helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Expiration Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
2- Name of Professional Liability Insurance Company helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Policy Number helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Amount of Coverage helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Expiration Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
SQE-MST-002 5 of 16
General Policies
Attachment to Application for Medical Staff Appointment
1 Members of the Active Medical Staff are expected to utilize the AUBMC available diagnostic
and therapeutic facilities for the care of their patients The facilities at the AUBMC are under
constant upgrading and reassessment to maintain them at the highest possible level of proficiency
2 Members of the Active Medical Staff on full time appointment in the Faculty of Medicine shall restrict their professional practice to the AUBMC its Outpatient Department or other medical
care facility administered by the AUBMC as assigned by the Chairperson of the Department
and the Dean except for consultations
3 Members of the Active Medical Staff on clinical appointment in the Faculty of Medicine shall
be actively engaged in teachingresearchservice at the Medical Center as assigned by their
respective Departmental Chairperson for a minimum of 600 hoursyear (12 hoursweek) They shall be expected to maintain the AUBMC as the primary facility for their private patients
4 Members of the Active Medical Staff are expected to 51 Attend department meetings
52 Attend meetings of the Medical Staff
53 Serve on committees
5 The foregoing duties as well as the educational and other professional responsibilities of a
member of the Active Medical Staff are concomitants of the privileges of admitting patients to
the AUBMC The continuation of this privilege depends upon conscientious and verifiable carrying out of these responsibilities
6 Members of the Clinical Associate Medical Staff appointed as ldquoAssociatesrdquo in the Faculty of Medicine shall be expected to be actively engaged in teachingresearch at the Medical Center
as assigned by their respective Departmental Chairperson for a minimum of 200 hoursyear (4
hoursweek)
7 Corrective measures and disciplinary action may be taken for violation of the Bylaws and
Rules and Regulations An appeal mechanism safeguards the rights of the individual
8 If appointed to the Medical Staff I hereby pledge that I will abide by and support the Bylaws
Rules and Regulations of the Medical Staff of the Medical Center of the American University
of Beirut as amended from time to time and to abide by the above set of general policies
Name_____________________ Signature _____________ Date ____________ (Print)
SQE-MST-002 6 of 16
DISCLOSURE QUESTIONS
Are you now or have you ever been subject to (provide FULL details for positive answers on a
separate sheet) Please place a check mark on each line YES NO
1 Previously successful or currently pending limitation suspension revocation
voluntary or involuntary surrender of license or registration to practice in any
jurisdiction
2 Previously successful or currently pending limitation suspension revocation
voluntary or involuntary surrender of Drug Enforcement Administration (DEA)
registration or its equivalent
3 Limitation suspension probation revocation denial non-renewal voluntary or
involuntary surrender of employment appointment privileges or training at any
hospital or health care related institution
4 Withdrawal of your application for appointment reappointment or clinical
privileges or resignation from a medical staff before a potentially adverse decision was made by a hospitalrsquos or health care facilityrsquos governing board
5 Formal investigation corrective action or discipline by any hospital or health
care related institution for any reason including patient complaints
6 Pending professional malpractice claims or actions medical conduct proceedings
or licensing board actions in any jurisdiction
7 Any judgment settlement or findings of medical malpractice or any findings of
professional misconduct in any jurisdiction please complete the Professional
Liability Explanation Form)
8 Suspension sanction or other restriction in participation in any private Federal or
State insurance program (eg Medicare) or similar entities
9 Current police or agency investigation substantiated charges or convictions for
sexual harassment sexual abuse child abuse elder abuse findings pertinent to
violations of patientrsquos rights or other human rights violations
10 Criminal convictions pending criminal proceedings or arrests for felonies or
misdemeanors
11 Malpractice premium ldquoratingrdquo surcharge malpractice insurance cancellation
denial or non-renewal
12 Resignation withdrawal or termination of your position with a professional
association or health maintenance organization for reasons related to clinical
quality or patient care issues
13 Do you currently have any physical or mental condition that impairs or could impair
your ability to practice medicine
14 Do you currently habitually use drugs or alcohol or have a dependence on drugs or alcohol (or have you ever had such habitual use of or dependence on drugs or
alcohol) that impairs or could impair your ability to practice medicine
SQE-MST-002 7 of 16
PROFESSIONAL LIABILITY EXPLANATION FORM
This form must be completed if you answered ldquoyesrdquo to question 9 on page 13 of the Medical Staff Application
Form
Please complete this form for each pending or settled professional liability claim or lawsuit and any payment
made on behalf of applicant All questions must be answered completely If additional sheets are required please photocopy this page prior to completing Please provide us with a separate sheet for each malpractice claim or
lawsuit
Date of Alleged Incident helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date Claim Made or Suit Filed helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Patient Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Location of Incident helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Your Relationship to Patient (Attending Practitioner Surgeon Assistant Surgeon Consultant etc)
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Allegation helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Liability Carrier when Incident Occurred helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Additional Named Defendant(s) [if applicable] helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Status
1048576 Open ndash If open amount being sought$ helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
1048576 Closedndash If closed indicate method of closing 1048576Dismissal 1048576Settlement 1048576Judgement
Amount of Settlement of Judgment $helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Summary Summarize the circumstances giving rise to the matter If the matter involves patient care provide a narrative
describing your care and treatment of the patient If additional space is necessary attach adequate clinical detail
to allow proper evaluation by a committee of physicians Include (1) Condition and diagnosis at time of incident
(2) dates and description of treatment rendered (3) condition of patient subsequent to treatment and (4) other
relevant information Please print helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip helliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
SQE-MST-002 8 of 16
Signature (stamped signatures are not accepted) Date
Printed Name
SQE-MST-002 9 of 16
Attestations Acknowledgements and Release form
I fully understand that any significant misstatement(s) or omissions from this application
constitute cause for denial of appointment or cause for termination of appointment even
after recruitment to the Medical Staff at AUBMC I am also waiving any right of action or other
means of redress The information submitted by me in this application is true to the best of my
knowledge and belief I am willing to appear for interviews in regard to my application I
understand and agree that I as the applicant have the burden of producing adequate
information for proper evaluation of my application
I acknowledge that I have received and read the Bylaws Rules and Regulations for the
medical staff at AUBMC the policies relevant to the application process and generally to
clinical practice at the Medical Center and agree to be bound by the terms thereof in all
matters relating to staff membership and clinical privileges
By applying for appointment or reappointment to medical staff at AUBMC I hereby authorize
the Medical Staff Office to obtain information concerning my professional competence
character ethics and health to support my application I also authorize the release of this
information within AUBMC and to any of its affiliated Medical Centers The Medical Center
may use this information for any lawful purpose it deems appropriate
I consent to inspection by AUBMC its Medical Staff and their representatives of all documents
that may be material to an evaluation of my qualifications and competence I release from
liability any and all individuals and organizations who provide information to AUBMC in good
faith and without malice concerning my professional competence background experience
ethics character utilization practice patterns health status and other qualifications for staff
appointment and clinical privileges and I consent to the release of such information
I acknowledge that I have the necessary credentials to request the attached privileges and
that I am mentally and physically capable of performing them To the best of my knowledge I
have no physical or behavioral conditions that have affected or may affect my ability to
perform the clinical privileges requested I hereby agree to undergo at any time upon request
a mental or physical examination satisfactory to AUBMC and if there is a mental or physical
impairment to provide evidence satisfactory to AUBMC that the impairment does not
interfere with my competence to provide care to patients
I pledge to maintain an ethical practice to provide for continuous care to my patients to
accept committee assignments to accept consultation and to participate in hospital
activities as assigned by the chairperson of the Department Specifically I pledge to abide by
the professional fees established by AUBMC not to receive from or pay another physician
I fully understand that the patient has the right to the confidentiality of hisher medical
information and that heshe has the right to approve or refuse the release of specific
information
I affirm that I am the person referred to in the foregoing application
Signature Date
Appendix 64 SQE-MST-002
SQE-MST-002 10 of 16
CODE OF ETHICS
Approved by the Medical Board on November 4 2003
The following principles should serve as a guide to ethical behavior for all Medical Staff
Medical Staff must recognize their responsibility not only to patients but also to society to
other medical and paramedical staff medical students and to themselves The following
principles are standards of conduct that define the essentials of honorable behavior for all
Medical Staff
1 - Medical Staff shall be dedicated to providing competent health care to all patients
with compassion and respect for human dignity
2 - Medical Staff shall deal honestly with patients and colleagues
3 - Medical Staff shall respect the rights of patients and of other Medical Staff
and shall safeguard patient confidences within the constraint of the law
4 - Medical Staff shall continue to study apply and advance scientific knowledge
make relevant information available to patients colleagues and to the public
obtain consultation and use the expertise of other Medical Staff when indicated
5 - Medical Staff shall respect the patientrsquos right to ask for a second opinion or the
transfer of his care to another physician
6 - Medical Staff who deem it necessary to transfer the care of a particular
patient to another Medical Staff member
A - The request shall be made to the Medical Staff member In case of
conflict it should be referred to division or department head
B - The Medical Staff member shall continue to provide the patient with
competent health care until such time as the patientrsquos care is transferred
to another Medical Staff member
7 - Medical Staff shall recognize that patients are best served by continuity of
health care and shall promote the coordination of care with other Medical teams
involved in the patientrsquos treatment
8 - Medical Staff shall not take financial advantage of patients and shall
adhere to the internal rules of professional fees
9 - Medical Staff shall recognize a responsibility to participate in activities
contributing to an improved community
10- Medical Staff shall abide by the University Policy on ldquoDuality or Conflict of Interestrdquo
11 - Medical Staff shall abide by the Lebanese Order of Physicians and the
Ministry of Health Codes on ethical behavior
Appendix 65
SQE-MST-002
SQE-MST-002 11 of 16
Appendix 66
SQE-MST-002
SQE-MST-002 12 of 16
SQE-MST-002 13 of 16
SQE-MST-002 14 of 16
SQE-MST-002 15 of 16
Appendix 67
SQE-MST-002
SQE-MST-002 16 of 16
CONFIDENTIALITY OF INFORMATION STATEMENT
I the undersigned do hereby declare and acknowledge that in connection
with and during my employment work training at the American University of
Beirut and its Medical Center (AUBAUBMC) I may have access to certain
information data materials documents and records in various forms written
verbal and computerized or otherwise (jointly referred to as the confidential
information) related to patient care research and financial data at AUBMC
As an employee of AUBMC it is my responsibility to maintain the confidentiality
of all such information
Additionally I understand that accessing patientsrsquo medical information stored
either in hard copies or in electronic form (Electronic health records include
but not limited to radiology laboratory other results medications and clinical
notes) is limited to my scope of work at AUBMC on the principle of need-to-
know basis
I understand that an audit trail noting my access to any of the above
information may be conducted and if Irsquom found to be in violation then
disciplinary action may be taken by the AUBAUBMC
I also declare and acknowledge that any violation of the foregoing will cause
AUBAUBMC immediate and irreparable harm that money cannot adequately
remedy and that AUBAUBMC shall be entitled to terminate my employment
work training in addition to obtaining any other remedies available at law
After my employment work training at AUBAUBMC regardless of the reason
for leaving I agree and undertake to abide by all AUBAUBMC confidentiality
rules and procedures and I will preserve and maintain all the information in
strict confidence and will not use disclose or in any other way divulge the
information except when authorized by AUBAUBMC
Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Appendix 68
SQE-MST-002
SQE-MST-002 2 of 16
Application for Initial Appointment to the Medical Staff
TO Chairperson Department of ________________________________________
I wish to apply for appointment to
the
First Middle Last following category
___ Active ___ with admitting
___ Associate Medical Staff Membership ___ with consultation privileges to
AUBMC
___ Emeritus ___ without admitting
___ Honorary
Period of Faculty Appointment __________________________
The following are attached
Request of Clinical Privileges for the Specialty of _______________ Subspecialty of ____________
(if applicable)
A signed form for Disclosure of Activities which may involve Conflict of Interest
_____________________________________________
___________________________________
Applicant Signature Date
Chairpersons Recommendation
I agree with this applicantrsquos statement of health status
I recommend appointment to the following Category
___ Active ___ with admitting
___ Associate Medical Staff Membership ___ with consultation privileges to
AUBMC
___ Emeritus ___ without admitting
___ Honorary
I concur with the attached Clinical Privileges as requested on the form
I do not concur with the requested Privileges The reason(s) for changes have been discussed with
the applicant on _________________ and heshe understood and accepted (See changes on the
form)
I do not recommend appointment for the following reason(s)
___________________________________________________________________________________
_____________________________________ ______________
Chairperson Signature Date
Medical Board Action Date of Action________________________________
Approved as requested Approved with modification Not approved
Chief of Staff ____________________________________________ Date signed
________________________________ Signature
Appendix 62
SQE-MST-002
SQE-MST-002 3 of 16
Curriculum Vitae for Initial Appointment to the Medical
Staff
PERSONAL DATA
Full Name First Middle Last
Specialty
Subspecialty
Date of Birth
Day Month Year
Place of Birth
Residence Address
Street
City
Phone Cell Phone
Office Address
Street
City
Phone
EDUCATION (please include in CV)
Undergraduate
Graduate
Postgraduate Training
LICENSURE AND CERTIFICATION
Lebanese Licensure
Date of Lebanese Ministry of Health Licensure License No
Lebanese Order of Physicians registration number
Issue DateEnd Date
Has your License to practice Medicine in Lebanon ever been under any kind of investigation 1048576 Yes 1048576No
If yes please complete the following details
1- Date of Investigation Type of Investigation
Result of Investigation
2- Date of Investigation Type of Investigation
Result of Investigation
National Social Security Fund participation number Issue Date
Other Licenses
1- CountryState Status Issue DateEnd Date
Picture
Appendix 63
SQE-MST-002
SQE-MST-002 4 of 16
2- CountryState StatusIssue DateEnd Date
3- CountryState StatusIssue DateEnd Date
4- CountryState StatusIssue DateEnd Date
5- CountryState Status Issue DateEnd Date
SPECIALTY BOARD CERTIFICATION(S) (please include in CV)
APPOINTMENTS (please include in CV)
Hospital Appointments
Academic Appointments
SCIENTIFIC AND MEDICAL SOCEITY MEMBERSHIPS
Please include in CV
CARDIOPULMONARY RESUSCITATION (CPR) TRAINING ( as per the policy ldquoResuscitative training
3rd Edition SQE ndashMUL -001rdquo
Yes No
I have completed training in BLSACLS copy of certificate is attached
I am not trained in CPR but I am willing to enroll in training and I will
send a copy of certificate upon completion
I am unable to qualify for BLSACLS for the following reasons
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
PREVIOUS AND CURRENT PROFESSIONAL LIABILITY INSURANCE
1- Name of Professional Liability Insurance Company helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Policy Number helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Amount of Coverage helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Expiration Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
2- Name of Professional Liability Insurance Company helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Policy Number helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Amount of Coverage helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Expiration Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
SQE-MST-002 5 of 16
General Policies
Attachment to Application for Medical Staff Appointment
1 Members of the Active Medical Staff are expected to utilize the AUBMC available diagnostic
and therapeutic facilities for the care of their patients The facilities at the AUBMC are under
constant upgrading and reassessment to maintain them at the highest possible level of proficiency
2 Members of the Active Medical Staff on full time appointment in the Faculty of Medicine shall restrict their professional practice to the AUBMC its Outpatient Department or other medical
care facility administered by the AUBMC as assigned by the Chairperson of the Department
and the Dean except for consultations
3 Members of the Active Medical Staff on clinical appointment in the Faculty of Medicine shall
be actively engaged in teachingresearchservice at the Medical Center as assigned by their
respective Departmental Chairperson for a minimum of 600 hoursyear (12 hoursweek) They shall be expected to maintain the AUBMC as the primary facility for their private patients
4 Members of the Active Medical Staff are expected to 51 Attend department meetings
52 Attend meetings of the Medical Staff
53 Serve on committees
5 The foregoing duties as well as the educational and other professional responsibilities of a
member of the Active Medical Staff are concomitants of the privileges of admitting patients to
the AUBMC The continuation of this privilege depends upon conscientious and verifiable carrying out of these responsibilities
6 Members of the Clinical Associate Medical Staff appointed as ldquoAssociatesrdquo in the Faculty of Medicine shall be expected to be actively engaged in teachingresearch at the Medical Center
as assigned by their respective Departmental Chairperson for a minimum of 200 hoursyear (4
hoursweek)
7 Corrective measures and disciplinary action may be taken for violation of the Bylaws and
Rules and Regulations An appeal mechanism safeguards the rights of the individual
8 If appointed to the Medical Staff I hereby pledge that I will abide by and support the Bylaws
Rules and Regulations of the Medical Staff of the Medical Center of the American University
of Beirut as amended from time to time and to abide by the above set of general policies
Name_____________________ Signature _____________ Date ____________ (Print)
SQE-MST-002 6 of 16
DISCLOSURE QUESTIONS
Are you now or have you ever been subject to (provide FULL details for positive answers on a
separate sheet) Please place a check mark on each line YES NO
1 Previously successful or currently pending limitation suspension revocation
voluntary or involuntary surrender of license or registration to practice in any
jurisdiction
2 Previously successful or currently pending limitation suspension revocation
voluntary or involuntary surrender of Drug Enforcement Administration (DEA)
registration or its equivalent
3 Limitation suspension probation revocation denial non-renewal voluntary or
involuntary surrender of employment appointment privileges or training at any
hospital or health care related institution
4 Withdrawal of your application for appointment reappointment or clinical
privileges or resignation from a medical staff before a potentially adverse decision was made by a hospitalrsquos or health care facilityrsquos governing board
5 Formal investigation corrective action or discipline by any hospital or health
care related institution for any reason including patient complaints
6 Pending professional malpractice claims or actions medical conduct proceedings
or licensing board actions in any jurisdiction
7 Any judgment settlement or findings of medical malpractice or any findings of
professional misconduct in any jurisdiction please complete the Professional
Liability Explanation Form)
8 Suspension sanction or other restriction in participation in any private Federal or
State insurance program (eg Medicare) or similar entities
9 Current police or agency investigation substantiated charges or convictions for
sexual harassment sexual abuse child abuse elder abuse findings pertinent to
violations of patientrsquos rights or other human rights violations
10 Criminal convictions pending criminal proceedings or arrests for felonies or
misdemeanors
11 Malpractice premium ldquoratingrdquo surcharge malpractice insurance cancellation
denial or non-renewal
12 Resignation withdrawal or termination of your position with a professional
association or health maintenance organization for reasons related to clinical
quality or patient care issues
13 Do you currently have any physical or mental condition that impairs or could impair
your ability to practice medicine
14 Do you currently habitually use drugs or alcohol or have a dependence on drugs or alcohol (or have you ever had such habitual use of or dependence on drugs or
alcohol) that impairs or could impair your ability to practice medicine
SQE-MST-002 7 of 16
PROFESSIONAL LIABILITY EXPLANATION FORM
This form must be completed if you answered ldquoyesrdquo to question 9 on page 13 of the Medical Staff Application
Form
Please complete this form for each pending or settled professional liability claim or lawsuit and any payment
made on behalf of applicant All questions must be answered completely If additional sheets are required please photocopy this page prior to completing Please provide us with a separate sheet for each malpractice claim or
lawsuit
Date of Alleged Incident helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date Claim Made or Suit Filed helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Patient Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Location of Incident helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Your Relationship to Patient (Attending Practitioner Surgeon Assistant Surgeon Consultant etc)
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Allegation helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Liability Carrier when Incident Occurred helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Additional Named Defendant(s) [if applicable] helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Status
1048576 Open ndash If open amount being sought$ helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
1048576 Closedndash If closed indicate method of closing 1048576Dismissal 1048576Settlement 1048576Judgement
Amount of Settlement of Judgment $helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Summary Summarize the circumstances giving rise to the matter If the matter involves patient care provide a narrative
describing your care and treatment of the patient If additional space is necessary attach adequate clinical detail
to allow proper evaluation by a committee of physicians Include (1) Condition and diagnosis at time of incident
(2) dates and description of treatment rendered (3) condition of patient subsequent to treatment and (4) other
relevant information Please print helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip helliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
SQE-MST-002 8 of 16
Signature (stamped signatures are not accepted) Date
Printed Name
SQE-MST-002 9 of 16
Attestations Acknowledgements and Release form
I fully understand that any significant misstatement(s) or omissions from this application
constitute cause for denial of appointment or cause for termination of appointment even
after recruitment to the Medical Staff at AUBMC I am also waiving any right of action or other
means of redress The information submitted by me in this application is true to the best of my
knowledge and belief I am willing to appear for interviews in regard to my application I
understand and agree that I as the applicant have the burden of producing adequate
information for proper evaluation of my application
I acknowledge that I have received and read the Bylaws Rules and Regulations for the
medical staff at AUBMC the policies relevant to the application process and generally to
clinical practice at the Medical Center and agree to be bound by the terms thereof in all
matters relating to staff membership and clinical privileges
By applying for appointment or reappointment to medical staff at AUBMC I hereby authorize
the Medical Staff Office to obtain information concerning my professional competence
character ethics and health to support my application I also authorize the release of this
information within AUBMC and to any of its affiliated Medical Centers The Medical Center
may use this information for any lawful purpose it deems appropriate
I consent to inspection by AUBMC its Medical Staff and their representatives of all documents
that may be material to an evaluation of my qualifications and competence I release from
liability any and all individuals and organizations who provide information to AUBMC in good
faith and without malice concerning my professional competence background experience
ethics character utilization practice patterns health status and other qualifications for staff
appointment and clinical privileges and I consent to the release of such information
I acknowledge that I have the necessary credentials to request the attached privileges and
that I am mentally and physically capable of performing them To the best of my knowledge I
have no physical or behavioral conditions that have affected or may affect my ability to
perform the clinical privileges requested I hereby agree to undergo at any time upon request
a mental or physical examination satisfactory to AUBMC and if there is a mental or physical
impairment to provide evidence satisfactory to AUBMC that the impairment does not
interfere with my competence to provide care to patients
I pledge to maintain an ethical practice to provide for continuous care to my patients to
accept committee assignments to accept consultation and to participate in hospital
activities as assigned by the chairperson of the Department Specifically I pledge to abide by
the professional fees established by AUBMC not to receive from or pay another physician
I fully understand that the patient has the right to the confidentiality of hisher medical
information and that heshe has the right to approve or refuse the release of specific
information
I affirm that I am the person referred to in the foregoing application
Signature Date
Appendix 64 SQE-MST-002
SQE-MST-002 10 of 16
CODE OF ETHICS
Approved by the Medical Board on November 4 2003
The following principles should serve as a guide to ethical behavior for all Medical Staff
Medical Staff must recognize their responsibility not only to patients but also to society to
other medical and paramedical staff medical students and to themselves The following
principles are standards of conduct that define the essentials of honorable behavior for all
Medical Staff
1 - Medical Staff shall be dedicated to providing competent health care to all patients
with compassion and respect for human dignity
2 - Medical Staff shall deal honestly with patients and colleagues
3 - Medical Staff shall respect the rights of patients and of other Medical Staff
and shall safeguard patient confidences within the constraint of the law
4 - Medical Staff shall continue to study apply and advance scientific knowledge
make relevant information available to patients colleagues and to the public
obtain consultation and use the expertise of other Medical Staff when indicated
5 - Medical Staff shall respect the patientrsquos right to ask for a second opinion or the
transfer of his care to another physician
6 - Medical Staff who deem it necessary to transfer the care of a particular
patient to another Medical Staff member
A - The request shall be made to the Medical Staff member In case of
conflict it should be referred to division or department head
B - The Medical Staff member shall continue to provide the patient with
competent health care until such time as the patientrsquos care is transferred
to another Medical Staff member
7 - Medical Staff shall recognize that patients are best served by continuity of
health care and shall promote the coordination of care with other Medical teams
involved in the patientrsquos treatment
8 - Medical Staff shall not take financial advantage of patients and shall
adhere to the internal rules of professional fees
9 - Medical Staff shall recognize a responsibility to participate in activities
contributing to an improved community
10- Medical Staff shall abide by the University Policy on ldquoDuality or Conflict of Interestrdquo
11 - Medical Staff shall abide by the Lebanese Order of Physicians and the
Ministry of Health Codes on ethical behavior
Appendix 65
SQE-MST-002
SQE-MST-002 11 of 16
Appendix 66
SQE-MST-002
SQE-MST-002 12 of 16
SQE-MST-002 13 of 16
SQE-MST-002 14 of 16
SQE-MST-002 15 of 16
Appendix 67
SQE-MST-002
SQE-MST-002 16 of 16
CONFIDENTIALITY OF INFORMATION STATEMENT
I the undersigned do hereby declare and acknowledge that in connection
with and during my employment work training at the American University of
Beirut and its Medical Center (AUBAUBMC) I may have access to certain
information data materials documents and records in various forms written
verbal and computerized or otherwise (jointly referred to as the confidential
information) related to patient care research and financial data at AUBMC
As an employee of AUBMC it is my responsibility to maintain the confidentiality
of all such information
Additionally I understand that accessing patientsrsquo medical information stored
either in hard copies or in electronic form (Electronic health records include
but not limited to radiology laboratory other results medications and clinical
notes) is limited to my scope of work at AUBMC on the principle of need-to-
know basis
I understand that an audit trail noting my access to any of the above
information may be conducted and if Irsquom found to be in violation then
disciplinary action may be taken by the AUBAUBMC
I also declare and acknowledge that any violation of the foregoing will cause
AUBAUBMC immediate and irreparable harm that money cannot adequately
remedy and that AUBAUBMC shall be entitled to terminate my employment
work training in addition to obtaining any other remedies available at law
After my employment work training at AUBAUBMC regardless of the reason
for leaving I agree and undertake to abide by all AUBAUBMC confidentiality
rules and procedures and I will preserve and maintain all the information in
strict confidence and will not use disclose or in any other way divulge the
information except when authorized by AUBAUBMC
Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Appendix 68
SQE-MST-002
SQE-MST-002 3 of 16
Curriculum Vitae for Initial Appointment to the Medical
Staff
PERSONAL DATA
Full Name First Middle Last
Specialty
Subspecialty
Date of Birth
Day Month Year
Place of Birth
Residence Address
Street
City
Phone Cell Phone
Office Address
Street
City
Phone
EDUCATION (please include in CV)
Undergraduate
Graduate
Postgraduate Training
LICENSURE AND CERTIFICATION
Lebanese Licensure
Date of Lebanese Ministry of Health Licensure License No
Lebanese Order of Physicians registration number
Issue DateEnd Date
Has your License to practice Medicine in Lebanon ever been under any kind of investigation 1048576 Yes 1048576No
If yes please complete the following details
1- Date of Investigation Type of Investigation
Result of Investigation
2- Date of Investigation Type of Investigation
Result of Investigation
National Social Security Fund participation number Issue Date
Other Licenses
1- CountryState Status Issue DateEnd Date
Picture
Appendix 63
SQE-MST-002
SQE-MST-002 4 of 16
2- CountryState StatusIssue DateEnd Date
3- CountryState StatusIssue DateEnd Date
4- CountryState StatusIssue DateEnd Date
5- CountryState Status Issue DateEnd Date
SPECIALTY BOARD CERTIFICATION(S) (please include in CV)
APPOINTMENTS (please include in CV)
Hospital Appointments
Academic Appointments
SCIENTIFIC AND MEDICAL SOCEITY MEMBERSHIPS
Please include in CV
CARDIOPULMONARY RESUSCITATION (CPR) TRAINING ( as per the policy ldquoResuscitative training
3rd Edition SQE ndashMUL -001rdquo
Yes No
I have completed training in BLSACLS copy of certificate is attached
I am not trained in CPR but I am willing to enroll in training and I will
send a copy of certificate upon completion
I am unable to qualify for BLSACLS for the following reasons
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
PREVIOUS AND CURRENT PROFESSIONAL LIABILITY INSURANCE
1- Name of Professional Liability Insurance Company helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Policy Number helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Amount of Coverage helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Expiration Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
2- Name of Professional Liability Insurance Company helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Policy Number helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Amount of Coverage helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Expiration Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
SQE-MST-002 5 of 16
General Policies
Attachment to Application for Medical Staff Appointment
1 Members of the Active Medical Staff are expected to utilize the AUBMC available diagnostic
and therapeutic facilities for the care of their patients The facilities at the AUBMC are under
constant upgrading and reassessment to maintain them at the highest possible level of proficiency
2 Members of the Active Medical Staff on full time appointment in the Faculty of Medicine shall restrict their professional practice to the AUBMC its Outpatient Department or other medical
care facility administered by the AUBMC as assigned by the Chairperson of the Department
and the Dean except for consultations
3 Members of the Active Medical Staff on clinical appointment in the Faculty of Medicine shall
be actively engaged in teachingresearchservice at the Medical Center as assigned by their
respective Departmental Chairperson for a minimum of 600 hoursyear (12 hoursweek) They shall be expected to maintain the AUBMC as the primary facility for their private patients
4 Members of the Active Medical Staff are expected to 51 Attend department meetings
52 Attend meetings of the Medical Staff
53 Serve on committees
5 The foregoing duties as well as the educational and other professional responsibilities of a
member of the Active Medical Staff are concomitants of the privileges of admitting patients to
the AUBMC The continuation of this privilege depends upon conscientious and verifiable carrying out of these responsibilities
6 Members of the Clinical Associate Medical Staff appointed as ldquoAssociatesrdquo in the Faculty of Medicine shall be expected to be actively engaged in teachingresearch at the Medical Center
as assigned by their respective Departmental Chairperson for a minimum of 200 hoursyear (4
hoursweek)
7 Corrective measures and disciplinary action may be taken for violation of the Bylaws and
Rules and Regulations An appeal mechanism safeguards the rights of the individual
8 If appointed to the Medical Staff I hereby pledge that I will abide by and support the Bylaws
Rules and Regulations of the Medical Staff of the Medical Center of the American University
of Beirut as amended from time to time and to abide by the above set of general policies
Name_____________________ Signature _____________ Date ____________ (Print)
SQE-MST-002 6 of 16
DISCLOSURE QUESTIONS
Are you now or have you ever been subject to (provide FULL details for positive answers on a
separate sheet) Please place a check mark on each line YES NO
1 Previously successful or currently pending limitation suspension revocation
voluntary or involuntary surrender of license or registration to practice in any
jurisdiction
2 Previously successful or currently pending limitation suspension revocation
voluntary or involuntary surrender of Drug Enforcement Administration (DEA)
registration or its equivalent
3 Limitation suspension probation revocation denial non-renewal voluntary or
involuntary surrender of employment appointment privileges or training at any
hospital or health care related institution
4 Withdrawal of your application for appointment reappointment or clinical
privileges or resignation from a medical staff before a potentially adverse decision was made by a hospitalrsquos or health care facilityrsquos governing board
5 Formal investigation corrective action or discipline by any hospital or health
care related institution for any reason including patient complaints
6 Pending professional malpractice claims or actions medical conduct proceedings
or licensing board actions in any jurisdiction
7 Any judgment settlement or findings of medical malpractice or any findings of
professional misconduct in any jurisdiction please complete the Professional
Liability Explanation Form)
8 Suspension sanction or other restriction in participation in any private Federal or
State insurance program (eg Medicare) or similar entities
9 Current police or agency investigation substantiated charges or convictions for
sexual harassment sexual abuse child abuse elder abuse findings pertinent to
violations of patientrsquos rights or other human rights violations
10 Criminal convictions pending criminal proceedings or arrests for felonies or
misdemeanors
11 Malpractice premium ldquoratingrdquo surcharge malpractice insurance cancellation
denial or non-renewal
12 Resignation withdrawal or termination of your position with a professional
association or health maintenance organization for reasons related to clinical
quality or patient care issues
13 Do you currently have any physical or mental condition that impairs or could impair
your ability to practice medicine
14 Do you currently habitually use drugs or alcohol or have a dependence on drugs or alcohol (or have you ever had such habitual use of or dependence on drugs or
alcohol) that impairs or could impair your ability to practice medicine
SQE-MST-002 7 of 16
PROFESSIONAL LIABILITY EXPLANATION FORM
This form must be completed if you answered ldquoyesrdquo to question 9 on page 13 of the Medical Staff Application
Form
Please complete this form for each pending or settled professional liability claim or lawsuit and any payment
made on behalf of applicant All questions must be answered completely If additional sheets are required please photocopy this page prior to completing Please provide us with a separate sheet for each malpractice claim or
lawsuit
Date of Alleged Incident helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date Claim Made or Suit Filed helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Patient Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Location of Incident helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Your Relationship to Patient (Attending Practitioner Surgeon Assistant Surgeon Consultant etc)
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Allegation helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Liability Carrier when Incident Occurred helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Additional Named Defendant(s) [if applicable] helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Status
1048576 Open ndash If open amount being sought$ helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
1048576 Closedndash If closed indicate method of closing 1048576Dismissal 1048576Settlement 1048576Judgement
Amount of Settlement of Judgment $helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Summary Summarize the circumstances giving rise to the matter If the matter involves patient care provide a narrative
describing your care and treatment of the patient If additional space is necessary attach adequate clinical detail
to allow proper evaluation by a committee of physicians Include (1) Condition and diagnosis at time of incident
(2) dates and description of treatment rendered (3) condition of patient subsequent to treatment and (4) other
relevant information Please print helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip helliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
SQE-MST-002 8 of 16
Signature (stamped signatures are not accepted) Date
Printed Name
SQE-MST-002 9 of 16
Attestations Acknowledgements and Release form
I fully understand that any significant misstatement(s) or omissions from this application
constitute cause for denial of appointment or cause for termination of appointment even
after recruitment to the Medical Staff at AUBMC I am also waiving any right of action or other
means of redress The information submitted by me in this application is true to the best of my
knowledge and belief I am willing to appear for interviews in regard to my application I
understand and agree that I as the applicant have the burden of producing adequate
information for proper evaluation of my application
I acknowledge that I have received and read the Bylaws Rules and Regulations for the
medical staff at AUBMC the policies relevant to the application process and generally to
clinical practice at the Medical Center and agree to be bound by the terms thereof in all
matters relating to staff membership and clinical privileges
By applying for appointment or reappointment to medical staff at AUBMC I hereby authorize
the Medical Staff Office to obtain information concerning my professional competence
character ethics and health to support my application I also authorize the release of this
information within AUBMC and to any of its affiliated Medical Centers The Medical Center
may use this information for any lawful purpose it deems appropriate
I consent to inspection by AUBMC its Medical Staff and their representatives of all documents
that may be material to an evaluation of my qualifications and competence I release from
liability any and all individuals and organizations who provide information to AUBMC in good
faith and without malice concerning my professional competence background experience
ethics character utilization practice patterns health status and other qualifications for staff
appointment and clinical privileges and I consent to the release of such information
I acknowledge that I have the necessary credentials to request the attached privileges and
that I am mentally and physically capable of performing them To the best of my knowledge I
have no physical or behavioral conditions that have affected or may affect my ability to
perform the clinical privileges requested I hereby agree to undergo at any time upon request
a mental or physical examination satisfactory to AUBMC and if there is a mental or physical
impairment to provide evidence satisfactory to AUBMC that the impairment does not
interfere with my competence to provide care to patients
I pledge to maintain an ethical practice to provide for continuous care to my patients to
accept committee assignments to accept consultation and to participate in hospital
activities as assigned by the chairperson of the Department Specifically I pledge to abide by
the professional fees established by AUBMC not to receive from or pay another physician
I fully understand that the patient has the right to the confidentiality of hisher medical
information and that heshe has the right to approve or refuse the release of specific
information
I affirm that I am the person referred to in the foregoing application
Signature Date
Appendix 64 SQE-MST-002
SQE-MST-002 10 of 16
CODE OF ETHICS
Approved by the Medical Board on November 4 2003
The following principles should serve as a guide to ethical behavior for all Medical Staff
Medical Staff must recognize their responsibility not only to patients but also to society to
other medical and paramedical staff medical students and to themselves The following
principles are standards of conduct that define the essentials of honorable behavior for all
Medical Staff
1 - Medical Staff shall be dedicated to providing competent health care to all patients
with compassion and respect for human dignity
2 - Medical Staff shall deal honestly with patients and colleagues
3 - Medical Staff shall respect the rights of patients and of other Medical Staff
and shall safeguard patient confidences within the constraint of the law
4 - Medical Staff shall continue to study apply and advance scientific knowledge
make relevant information available to patients colleagues and to the public
obtain consultation and use the expertise of other Medical Staff when indicated
5 - Medical Staff shall respect the patientrsquos right to ask for a second opinion or the
transfer of his care to another physician
6 - Medical Staff who deem it necessary to transfer the care of a particular
patient to another Medical Staff member
A - The request shall be made to the Medical Staff member In case of
conflict it should be referred to division or department head
B - The Medical Staff member shall continue to provide the patient with
competent health care until such time as the patientrsquos care is transferred
to another Medical Staff member
7 - Medical Staff shall recognize that patients are best served by continuity of
health care and shall promote the coordination of care with other Medical teams
involved in the patientrsquos treatment
8 - Medical Staff shall not take financial advantage of patients and shall
adhere to the internal rules of professional fees
9 - Medical Staff shall recognize a responsibility to participate in activities
contributing to an improved community
10- Medical Staff shall abide by the University Policy on ldquoDuality or Conflict of Interestrdquo
11 - Medical Staff shall abide by the Lebanese Order of Physicians and the
Ministry of Health Codes on ethical behavior
Appendix 65
SQE-MST-002
SQE-MST-002 11 of 16
Appendix 66
SQE-MST-002
SQE-MST-002 12 of 16
SQE-MST-002 13 of 16
SQE-MST-002 14 of 16
SQE-MST-002 15 of 16
Appendix 67
SQE-MST-002
SQE-MST-002 16 of 16
CONFIDENTIALITY OF INFORMATION STATEMENT
I the undersigned do hereby declare and acknowledge that in connection
with and during my employment work training at the American University of
Beirut and its Medical Center (AUBAUBMC) I may have access to certain
information data materials documents and records in various forms written
verbal and computerized or otherwise (jointly referred to as the confidential
information) related to patient care research and financial data at AUBMC
As an employee of AUBMC it is my responsibility to maintain the confidentiality
of all such information
Additionally I understand that accessing patientsrsquo medical information stored
either in hard copies or in electronic form (Electronic health records include
but not limited to radiology laboratory other results medications and clinical
notes) is limited to my scope of work at AUBMC on the principle of need-to-
know basis
I understand that an audit trail noting my access to any of the above
information may be conducted and if Irsquom found to be in violation then
disciplinary action may be taken by the AUBAUBMC
I also declare and acknowledge that any violation of the foregoing will cause
AUBAUBMC immediate and irreparable harm that money cannot adequately
remedy and that AUBAUBMC shall be entitled to terminate my employment
work training in addition to obtaining any other remedies available at law
After my employment work training at AUBAUBMC regardless of the reason
for leaving I agree and undertake to abide by all AUBAUBMC confidentiality
rules and procedures and I will preserve and maintain all the information in
strict confidence and will not use disclose or in any other way divulge the
information except when authorized by AUBAUBMC
Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Appendix 68
SQE-MST-002
SQE-MST-002 4 of 16
2- CountryState StatusIssue DateEnd Date
3- CountryState StatusIssue DateEnd Date
4- CountryState StatusIssue DateEnd Date
5- CountryState Status Issue DateEnd Date
SPECIALTY BOARD CERTIFICATION(S) (please include in CV)
APPOINTMENTS (please include in CV)
Hospital Appointments
Academic Appointments
SCIENTIFIC AND MEDICAL SOCEITY MEMBERSHIPS
Please include in CV
CARDIOPULMONARY RESUSCITATION (CPR) TRAINING ( as per the policy ldquoResuscitative training
3rd Edition SQE ndashMUL -001rdquo
Yes No
I have completed training in BLSACLS copy of certificate is attached
I am not trained in CPR but I am willing to enroll in training and I will
send a copy of certificate upon completion
I am unable to qualify for BLSACLS for the following reasons
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
PREVIOUS AND CURRENT PROFESSIONAL LIABILITY INSURANCE
1- Name of Professional Liability Insurance Company helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Policy Number helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Amount of Coverage helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Expiration Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
2- Name of Professional Liability Insurance Company helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Policy Number helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Amount of Coverage helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Expiration Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
SQE-MST-002 5 of 16
General Policies
Attachment to Application for Medical Staff Appointment
1 Members of the Active Medical Staff are expected to utilize the AUBMC available diagnostic
and therapeutic facilities for the care of their patients The facilities at the AUBMC are under
constant upgrading and reassessment to maintain them at the highest possible level of proficiency
2 Members of the Active Medical Staff on full time appointment in the Faculty of Medicine shall restrict their professional practice to the AUBMC its Outpatient Department or other medical
care facility administered by the AUBMC as assigned by the Chairperson of the Department
and the Dean except for consultations
3 Members of the Active Medical Staff on clinical appointment in the Faculty of Medicine shall
be actively engaged in teachingresearchservice at the Medical Center as assigned by their
respective Departmental Chairperson for a minimum of 600 hoursyear (12 hoursweek) They shall be expected to maintain the AUBMC as the primary facility for their private patients
4 Members of the Active Medical Staff are expected to 51 Attend department meetings
52 Attend meetings of the Medical Staff
53 Serve on committees
5 The foregoing duties as well as the educational and other professional responsibilities of a
member of the Active Medical Staff are concomitants of the privileges of admitting patients to
the AUBMC The continuation of this privilege depends upon conscientious and verifiable carrying out of these responsibilities
6 Members of the Clinical Associate Medical Staff appointed as ldquoAssociatesrdquo in the Faculty of Medicine shall be expected to be actively engaged in teachingresearch at the Medical Center
as assigned by their respective Departmental Chairperson for a minimum of 200 hoursyear (4
hoursweek)
7 Corrective measures and disciplinary action may be taken for violation of the Bylaws and
Rules and Regulations An appeal mechanism safeguards the rights of the individual
8 If appointed to the Medical Staff I hereby pledge that I will abide by and support the Bylaws
Rules and Regulations of the Medical Staff of the Medical Center of the American University
of Beirut as amended from time to time and to abide by the above set of general policies
Name_____________________ Signature _____________ Date ____________ (Print)
SQE-MST-002 6 of 16
DISCLOSURE QUESTIONS
Are you now or have you ever been subject to (provide FULL details for positive answers on a
separate sheet) Please place a check mark on each line YES NO
1 Previously successful or currently pending limitation suspension revocation
voluntary or involuntary surrender of license or registration to practice in any
jurisdiction
2 Previously successful or currently pending limitation suspension revocation
voluntary or involuntary surrender of Drug Enforcement Administration (DEA)
registration or its equivalent
3 Limitation suspension probation revocation denial non-renewal voluntary or
involuntary surrender of employment appointment privileges or training at any
hospital or health care related institution
4 Withdrawal of your application for appointment reappointment or clinical
privileges or resignation from a medical staff before a potentially adverse decision was made by a hospitalrsquos or health care facilityrsquos governing board
5 Formal investigation corrective action or discipline by any hospital or health
care related institution for any reason including patient complaints
6 Pending professional malpractice claims or actions medical conduct proceedings
or licensing board actions in any jurisdiction
7 Any judgment settlement or findings of medical malpractice or any findings of
professional misconduct in any jurisdiction please complete the Professional
Liability Explanation Form)
8 Suspension sanction or other restriction in participation in any private Federal or
State insurance program (eg Medicare) or similar entities
9 Current police or agency investigation substantiated charges or convictions for
sexual harassment sexual abuse child abuse elder abuse findings pertinent to
violations of patientrsquos rights or other human rights violations
10 Criminal convictions pending criminal proceedings or arrests for felonies or
misdemeanors
11 Malpractice premium ldquoratingrdquo surcharge malpractice insurance cancellation
denial or non-renewal
12 Resignation withdrawal or termination of your position with a professional
association or health maintenance organization for reasons related to clinical
quality or patient care issues
13 Do you currently have any physical or mental condition that impairs or could impair
your ability to practice medicine
14 Do you currently habitually use drugs or alcohol or have a dependence on drugs or alcohol (or have you ever had such habitual use of or dependence on drugs or
alcohol) that impairs or could impair your ability to practice medicine
SQE-MST-002 7 of 16
PROFESSIONAL LIABILITY EXPLANATION FORM
This form must be completed if you answered ldquoyesrdquo to question 9 on page 13 of the Medical Staff Application
Form
Please complete this form for each pending or settled professional liability claim or lawsuit and any payment
made on behalf of applicant All questions must be answered completely If additional sheets are required please photocopy this page prior to completing Please provide us with a separate sheet for each malpractice claim or
lawsuit
Date of Alleged Incident helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date Claim Made or Suit Filed helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Patient Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Location of Incident helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Your Relationship to Patient (Attending Practitioner Surgeon Assistant Surgeon Consultant etc)
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Allegation helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Liability Carrier when Incident Occurred helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Additional Named Defendant(s) [if applicable] helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Status
1048576 Open ndash If open amount being sought$ helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
1048576 Closedndash If closed indicate method of closing 1048576Dismissal 1048576Settlement 1048576Judgement
Amount of Settlement of Judgment $helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Summary Summarize the circumstances giving rise to the matter If the matter involves patient care provide a narrative
describing your care and treatment of the patient If additional space is necessary attach adequate clinical detail
to allow proper evaluation by a committee of physicians Include (1) Condition and diagnosis at time of incident
(2) dates and description of treatment rendered (3) condition of patient subsequent to treatment and (4) other
relevant information Please print helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip helliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
SQE-MST-002 8 of 16
Signature (stamped signatures are not accepted) Date
Printed Name
SQE-MST-002 9 of 16
Attestations Acknowledgements and Release form
I fully understand that any significant misstatement(s) or omissions from this application
constitute cause for denial of appointment or cause for termination of appointment even
after recruitment to the Medical Staff at AUBMC I am also waiving any right of action or other
means of redress The information submitted by me in this application is true to the best of my
knowledge and belief I am willing to appear for interviews in regard to my application I
understand and agree that I as the applicant have the burden of producing adequate
information for proper evaluation of my application
I acknowledge that I have received and read the Bylaws Rules and Regulations for the
medical staff at AUBMC the policies relevant to the application process and generally to
clinical practice at the Medical Center and agree to be bound by the terms thereof in all
matters relating to staff membership and clinical privileges
By applying for appointment or reappointment to medical staff at AUBMC I hereby authorize
the Medical Staff Office to obtain information concerning my professional competence
character ethics and health to support my application I also authorize the release of this
information within AUBMC and to any of its affiliated Medical Centers The Medical Center
may use this information for any lawful purpose it deems appropriate
I consent to inspection by AUBMC its Medical Staff and their representatives of all documents
that may be material to an evaluation of my qualifications and competence I release from
liability any and all individuals and organizations who provide information to AUBMC in good
faith and without malice concerning my professional competence background experience
ethics character utilization practice patterns health status and other qualifications for staff
appointment and clinical privileges and I consent to the release of such information
I acknowledge that I have the necessary credentials to request the attached privileges and
that I am mentally and physically capable of performing them To the best of my knowledge I
have no physical or behavioral conditions that have affected or may affect my ability to
perform the clinical privileges requested I hereby agree to undergo at any time upon request
a mental or physical examination satisfactory to AUBMC and if there is a mental or physical
impairment to provide evidence satisfactory to AUBMC that the impairment does not
interfere with my competence to provide care to patients
I pledge to maintain an ethical practice to provide for continuous care to my patients to
accept committee assignments to accept consultation and to participate in hospital
activities as assigned by the chairperson of the Department Specifically I pledge to abide by
the professional fees established by AUBMC not to receive from or pay another physician
I fully understand that the patient has the right to the confidentiality of hisher medical
information and that heshe has the right to approve or refuse the release of specific
information
I affirm that I am the person referred to in the foregoing application
Signature Date
Appendix 64 SQE-MST-002
SQE-MST-002 10 of 16
CODE OF ETHICS
Approved by the Medical Board on November 4 2003
The following principles should serve as a guide to ethical behavior for all Medical Staff
Medical Staff must recognize their responsibility not only to patients but also to society to
other medical and paramedical staff medical students and to themselves The following
principles are standards of conduct that define the essentials of honorable behavior for all
Medical Staff
1 - Medical Staff shall be dedicated to providing competent health care to all patients
with compassion and respect for human dignity
2 - Medical Staff shall deal honestly with patients and colleagues
3 - Medical Staff shall respect the rights of patients and of other Medical Staff
and shall safeguard patient confidences within the constraint of the law
4 - Medical Staff shall continue to study apply and advance scientific knowledge
make relevant information available to patients colleagues and to the public
obtain consultation and use the expertise of other Medical Staff when indicated
5 - Medical Staff shall respect the patientrsquos right to ask for a second opinion or the
transfer of his care to another physician
6 - Medical Staff who deem it necessary to transfer the care of a particular
patient to another Medical Staff member
A - The request shall be made to the Medical Staff member In case of
conflict it should be referred to division or department head
B - The Medical Staff member shall continue to provide the patient with
competent health care until such time as the patientrsquos care is transferred
to another Medical Staff member
7 - Medical Staff shall recognize that patients are best served by continuity of
health care and shall promote the coordination of care with other Medical teams
involved in the patientrsquos treatment
8 - Medical Staff shall not take financial advantage of patients and shall
adhere to the internal rules of professional fees
9 - Medical Staff shall recognize a responsibility to participate in activities
contributing to an improved community
10- Medical Staff shall abide by the University Policy on ldquoDuality or Conflict of Interestrdquo
11 - Medical Staff shall abide by the Lebanese Order of Physicians and the
Ministry of Health Codes on ethical behavior
Appendix 65
SQE-MST-002
SQE-MST-002 11 of 16
Appendix 66
SQE-MST-002
SQE-MST-002 12 of 16
SQE-MST-002 13 of 16
SQE-MST-002 14 of 16
SQE-MST-002 15 of 16
Appendix 67
SQE-MST-002
SQE-MST-002 16 of 16
CONFIDENTIALITY OF INFORMATION STATEMENT
I the undersigned do hereby declare and acknowledge that in connection
with and during my employment work training at the American University of
Beirut and its Medical Center (AUBAUBMC) I may have access to certain
information data materials documents and records in various forms written
verbal and computerized or otherwise (jointly referred to as the confidential
information) related to patient care research and financial data at AUBMC
As an employee of AUBMC it is my responsibility to maintain the confidentiality
of all such information
Additionally I understand that accessing patientsrsquo medical information stored
either in hard copies or in electronic form (Electronic health records include
but not limited to radiology laboratory other results medications and clinical
notes) is limited to my scope of work at AUBMC on the principle of need-to-
know basis
I understand that an audit trail noting my access to any of the above
information may be conducted and if Irsquom found to be in violation then
disciplinary action may be taken by the AUBAUBMC
I also declare and acknowledge that any violation of the foregoing will cause
AUBAUBMC immediate and irreparable harm that money cannot adequately
remedy and that AUBAUBMC shall be entitled to terminate my employment
work training in addition to obtaining any other remedies available at law
After my employment work training at AUBAUBMC regardless of the reason
for leaving I agree and undertake to abide by all AUBAUBMC confidentiality
rules and procedures and I will preserve and maintain all the information in
strict confidence and will not use disclose or in any other way divulge the
information except when authorized by AUBAUBMC
Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Appendix 68
SQE-MST-002
SQE-MST-002 5 of 16
General Policies
Attachment to Application for Medical Staff Appointment
1 Members of the Active Medical Staff are expected to utilize the AUBMC available diagnostic
and therapeutic facilities for the care of their patients The facilities at the AUBMC are under
constant upgrading and reassessment to maintain them at the highest possible level of proficiency
2 Members of the Active Medical Staff on full time appointment in the Faculty of Medicine shall restrict their professional practice to the AUBMC its Outpatient Department or other medical
care facility administered by the AUBMC as assigned by the Chairperson of the Department
and the Dean except for consultations
3 Members of the Active Medical Staff on clinical appointment in the Faculty of Medicine shall
be actively engaged in teachingresearchservice at the Medical Center as assigned by their
respective Departmental Chairperson for a minimum of 600 hoursyear (12 hoursweek) They shall be expected to maintain the AUBMC as the primary facility for their private patients
4 Members of the Active Medical Staff are expected to 51 Attend department meetings
52 Attend meetings of the Medical Staff
53 Serve on committees
5 The foregoing duties as well as the educational and other professional responsibilities of a
member of the Active Medical Staff are concomitants of the privileges of admitting patients to
the AUBMC The continuation of this privilege depends upon conscientious and verifiable carrying out of these responsibilities
6 Members of the Clinical Associate Medical Staff appointed as ldquoAssociatesrdquo in the Faculty of Medicine shall be expected to be actively engaged in teachingresearch at the Medical Center
as assigned by their respective Departmental Chairperson for a minimum of 200 hoursyear (4
hoursweek)
7 Corrective measures and disciplinary action may be taken for violation of the Bylaws and
Rules and Regulations An appeal mechanism safeguards the rights of the individual
8 If appointed to the Medical Staff I hereby pledge that I will abide by and support the Bylaws
Rules and Regulations of the Medical Staff of the Medical Center of the American University
of Beirut as amended from time to time and to abide by the above set of general policies
Name_____________________ Signature _____________ Date ____________ (Print)
SQE-MST-002 6 of 16
DISCLOSURE QUESTIONS
Are you now or have you ever been subject to (provide FULL details for positive answers on a
separate sheet) Please place a check mark on each line YES NO
1 Previously successful or currently pending limitation suspension revocation
voluntary or involuntary surrender of license or registration to practice in any
jurisdiction
2 Previously successful or currently pending limitation suspension revocation
voluntary or involuntary surrender of Drug Enforcement Administration (DEA)
registration or its equivalent
3 Limitation suspension probation revocation denial non-renewal voluntary or
involuntary surrender of employment appointment privileges or training at any
hospital or health care related institution
4 Withdrawal of your application for appointment reappointment or clinical
privileges or resignation from a medical staff before a potentially adverse decision was made by a hospitalrsquos or health care facilityrsquos governing board
5 Formal investigation corrective action or discipline by any hospital or health
care related institution for any reason including patient complaints
6 Pending professional malpractice claims or actions medical conduct proceedings
or licensing board actions in any jurisdiction
7 Any judgment settlement or findings of medical malpractice or any findings of
professional misconduct in any jurisdiction please complete the Professional
Liability Explanation Form)
8 Suspension sanction or other restriction in participation in any private Federal or
State insurance program (eg Medicare) or similar entities
9 Current police or agency investigation substantiated charges or convictions for
sexual harassment sexual abuse child abuse elder abuse findings pertinent to
violations of patientrsquos rights or other human rights violations
10 Criminal convictions pending criminal proceedings or arrests for felonies or
misdemeanors
11 Malpractice premium ldquoratingrdquo surcharge malpractice insurance cancellation
denial or non-renewal
12 Resignation withdrawal or termination of your position with a professional
association or health maintenance organization for reasons related to clinical
quality or patient care issues
13 Do you currently have any physical or mental condition that impairs or could impair
your ability to practice medicine
14 Do you currently habitually use drugs or alcohol or have a dependence on drugs or alcohol (or have you ever had such habitual use of or dependence on drugs or
alcohol) that impairs or could impair your ability to practice medicine
SQE-MST-002 7 of 16
PROFESSIONAL LIABILITY EXPLANATION FORM
This form must be completed if you answered ldquoyesrdquo to question 9 on page 13 of the Medical Staff Application
Form
Please complete this form for each pending or settled professional liability claim or lawsuit and any payment
made on behalf of applicant All questions must be answered completely If additional sheets are required please photocopy this page prior to completing Please provide us with a separate sheet for each malpractice claim or
lawsuit
Date of Alleged Incident helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date Claim Made or Suit Filed helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Patient Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Location of Incident helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Your Relationship to Patient (Attending Practitioner Surgeon Assistant Surgeon Consultant etc)
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Allegation helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Liability Carrier when Incident Occurred helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Additional Named Defendant(s) [if applicable] helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Status
1048576 Open ndash If open amount being sought$ helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
1048576 Closedndash If closed indicate method of closing 1048576Dismissal 1048576Settlement 1048576Judgement
Amount of Settlement of Judgment $helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Summary Summarize the circumstances giving rise to the matter If the matter involves patient care provide a narrative
describing your care and treatment of the patient If additional space is necessary attach adequate clinical detail
to allow proper evaluation by a committee of physicians Include (1) Condition and diagnosis at time of incident
(2) dates and description of treatment rendered (3) condition of patient subsequent to treatment and (4) other
relevant information Please print helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip helliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
SQE-MST-002 8 of 16
Signature (stamped signatures are not accepted) Date
Printed Name
SQE-MST-002 9 of 16
Attestations Acknowledgements and Release form
I fully understand that any significant misstatement(s) or omissions from this application
constitute cause for denial of appointment or cause for termination of appointment even
after recruitment to the Medical Staff at AUBMC I am also waiving any right of action or other
means of redress The information submitted by me in this application is true to the best of my
knowledge and belief I am willing to appear for interviews in regard to my application I
understand and agree that I as the applicant have the burden of producing adequate
information for proper evaluation of my application
I acknowledge that I have received and read the Bylaws Rules and Regulations for the
medical staff at AUBMC the policies relevant to the application process and generally to
clinical practice at the Medical Center and agree to be bound by the terms thereof in all
matters relating to staff membership and clinical privileges
By applying for appointment or reappointment to medical staff at AUBMC I hereby authorize
the Medical Staff Office to obtain information concerning my professional competence
character ethics and health to support my application I also authorize the release of this
information within AUBMC and to any of its affiliated Medical Centers The Medical Center
may use this information for any lawful purpose it deems appropriate
I consent to inspection by AUBMC its Medical Staff and their representatives of all documents
that may be material to an evaluation of my qualifications and competence I release from
liability any and all individuals and organizations who provide information to AUBMC in good
faith and without malice concerning my professional competence background experience
ethics character utilization practice patterns health status and other qualifications for staff
appointment and clinical privileges and I consent to the release of such information
I acknowledge that I have the necessary credentials to request the attached privileges and
that I am mentally and physically capable of performing them To the best of my knowledge I
have no physical or behavioral conditions that have affected or may affect my ability to
perform the clinical privileges requested I hereby agree to undergo at any time upon request
a mental or physical examination satisfactory to AUBMC and if there is a mental or physical
impairment to provide evidence satisfactory to AUBMC that the impairment does not
interfere with my competence to provide care to patients
I pledge to maintain an ethical practice to provide for continuous care to my patients to
accept committee assignments to accept consultation and to participate in hospital
activities as assigned by the chairperson of the Department Specifically I pledge to abide by
the professional fees established by AUBMC not to receive from or pay another physician
I fully understand that the patient has the right to the confidentiality of hisher medical
information and that heshe has the right to approve or refuse the release of specific
information
I affirm that I am the person referred to in the foregoing application
Signature Date
Appendix 64 SQE-MST-002
SQE-MST-002 10 of 16
CODE OF ETHICS
Approved by the Medical Board on November 4 2003
The following principles should serve as a guide to ethical behavior for all Medical Staff
Medical Staff must recognize their responsibility not only to patients but also to society to
other medical and paramedical staff medical students and to themselves The following
principles are standards of conduct that define the essentials of honorable behavior for all
Medical Staff
1 - Medical Staff shall be dedicated to providing competent health care to all patients
with compassion and respect for human dignity
2 - Medical Staff shall deal honestly with patients and colleagues
3 - Medical Staff shall respect the rights of patients and of other Medical Staff
and shall safeguard patient confidences within the constraint of the law
4 - Medical Staff shall continue to study apply and advance scientific knowledge
make relevant information available to patients colleagues and to the public
obtain consultation and use the expertise of other Medical Staff when indicated
5 - Medical Staff shall respect the patientrsquos right to ask for a second opinion or the
transfer of his care to another physician
6 - Medical Staff who deem it necessary to transfer the care of a particular
patient to another Medical Staff member
A - The request shall be made to the Medical Staff member In case of
conflict it should be referred to division or department head
B - The Medical Staff member shall continue to provide the patient with
competent health care until such time as the patientrsquos care is transferred
to another Medical Staff member
7 - Medical Staff shall recognize that patients are best served by continuity of
health care and shall promote the coordination of care with other Medical teams
involved in the patientrsquos treatment
8 - Medical Staff shall not take financial advantage of patients and shall
adhere to the internal rules of professional fees
9 - Medical Staff shall recognize a responsibility to participate in activities
contributing to an improved community
10- Medical Staff shall abide by the University Policy on ldquoDuality or Conflict of Interestrdquo
11 - Medical Staff shall abide by the Lebanese Order of Physicians and the
Ministry of Health Codes on ethical behavior
Appendix 65
SQE-MST-002
SQE-MST-002 11 of 16
Appendix 66
SQE-MST-002
SQE-MST-002 12 of 16
SQE-MST-002 13 of 16
SQE-MST-002 14 of 16
SQE-MST-002 15 of 16
Appendix 67
SQE-MST-002
SQE-MST-002 16 of 16
CONFIDENTIALITY OF INFORMATION STATEMENT
I the undersigned do hereby declare and acknowledge that in connection
with and during my employment work training at the American University of
Beirut and its Medical Center (AUBAUBMC) I may have access to certain
information data materials documents and records in various forms written
verbal and computerized or otherwise (jointly referred to as the confidential
information) related to patient care research and financial data at AUBMC
As an employee of AUBMC it is my responsibility to maintain the confidentiality
of all such information
Additionally I understand that accessing patientsrsquo medical information stored
either in hard copies or in electronic form (Electronic health records include
but not limited to radiology laboratory other results medications and clinical
notes) is limited to my scope of work at AUBMC on the principle of need-to-
know basis
I understand that an audit trail noting my access to any of the above
information may be conducted and if Irsquom found to be in violation then
disciplinary action may be taken by the AUBAUBMC
I also declare and acknowledge that any violation of the foregoing will cause
AUBAUBMC immediate and irreparable harm that money cannot adequately
remedy and that AUBAUBMC shall be entitled to terminate my employment
work training in addition to obtaining any other remedies available at law
After my employment work training at AUBAUBMC regardless of the reason
for leaving I agree and undertake to abide by all AUBAUBMC confidentiality
rules and procedures and I will preserve and maintain all the information in
strict confidence and will not use disclose or in any other way divulge the
information except when authorized by AUBAUBMC
Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Appendix 68
SQE-MST-002
SQE-MST-002 6 of 16
DISCLOSURE QUESTIONS
Are you now or have you ever been subject to (provide FULL details for positive answers on a
separate sheet) Please place a check mark on each line YES NO
1 Previously successful or currently pending limitation suspension revocation
voluntary or involuntary surrender of license or registration to practice in any
jurisdiction
2 Previously successful or currently pending limitation suspension revocation
voluntary or involuntary surrender of Drug Enforcement Administration (DEA)
registration or its equivalent
3 Limitation suspension probation revocation denial non-renewal voluntary or
involuntary surrender of employment appointment privileges or training at any
hospital or health care related institution
4 Withdrawal of your application for appointment reappointment or clinical
privileges or resignation from a medical staff before a potentially adverse decision was made by a hospitalrsquos or health care facilityrsquos governing board
5 Formal investigation corrective action or discipline by any hospital or health
care related institution for any reason including patient complaints
6 Pending professional malpractice claims or actions medical conduct proceedings
or licensing board actions in any jurisdiction
7 Any judgment settlement or findings of medical malpractice or any findings of
professional misconduct in any jurisdiction please complete the Professional
Liability Explanation Form)
8 Suspension sanction or other restriction in participation in any private Federal or
State insurance program (eg Medicare) or similar entities
9 Current police or agency investigation substantiated charges or convictions for
sexual harassment sexual abuse child abuse elder abuse findings pertinent to
violations of patientrsquos rights or other human rights violations
10 Criminal convictions pending criminal proceedings or arrests for felonies or
misdemeanors
11 Malpractice premium ldquoratingrdquo surcharge malpractice insurance cancellation
denial or non-renewal
12 Resignation withdrawal or termination of your position with a professional
association or health maintenance organization for reasons related to clinical
quality or patient care issues
13 Do you currently have any physical or mental condition that impairs or could impair
your ability to practice medicine
14 Do you currently habitually use drugs or alcohol or have a dependence on drugs or alcohol (or have you ever had such habitual use of or dependence on drugs or
alcohol) that impairs or could impair your ability to practice medicine
SQE-MST-002 7 of 16
PROFESSIONAL LIABILITY EXPLANATION FORM
This form must be completed if you answered ldquoyesrdquo to question 9 on page 13 of the Medical Staff Application
Form
Please complete this form for each pending or settled professional liability claim or lawsuit and any payment
made on behalf of applicant All questions must be answered completely If additional sheets are required please photocopy this page prior to completing Please provide us with a separate sheet for each malpractice claim or
lawsuit
Date of Alleged Incident helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date Claim Made or Suit Filed helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Patient Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Location of Incident helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Your Relationship to Patient (Attending Practitioner Surgeon Assistant Surgeon Consultant etc)
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Allegation helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Liability Carrier when Incident Occurred helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Additional Named Defendant(s) [if applicable] helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Status
1048576 Open ndash If open amount being sought$ helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
1048576 Closedndash If closed indicate method of closing 1048576Dismissal 1048576Settlement 1048576Judgement
Amount of Settlement of Judgment $helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Summary Summarize the circumstances giving rise to the matter If the matter involves patient care provide a narrative
describing your care and treatment of the patient If additional space is necessary attach adequate clinical detail
to allow proper evaluation by a committee of physicians Include (1) Condition and diagnosis at time of incident
(2) dates and description of treatment rendered (3) condition of patient subsequent to treatment and (4) other
relevant information Please print helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip helliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
SQE-MST-002 8 of 16
Signature (stamped signatures are not accepted) Date
Printed Name
SQE-MST-002 9 of 16
Attestations Acknowledgements and Release form
I fully understand that any significant misstatement(s) or omissions from this application
constitute cause for denial of appointment or cause for termination of appointment even
after recruitment to the Medical Staff at AUBMC I am also waiving any right of action or other
means of redress The information submitted by me in this application is true to the best of my
knowledge and belief I am willing to appear for interviews in regard to my application I
understand and agree that I as the applicant have the burden of producing adequate
information for proper evaluation of my application
I acknowledge that I have received and read the Bylaws Rules and Regulations for the
medical staff at AUBMC the policies relevant to the application process and generally to
clinical practice at the Medical Center and agree to be bound by the terms thereof in all
matters relating to staff membership and clinical privileges
By applying for appointment or reappointment to medical staff at AUBMC I hereby authorize
the Medical Staff Office to obtain information concerning my professional competence
character ethics and health to support my application I also authorize the release of this
information within AUBMC and to any of its affiliated Medical Centers The Medical Center
may use this information for any lawful purpose it deems appropriate
I consent to inspection by AUBMC its Medical Staff and their representatives of all documents
that may be material to an evaluation of my qualifications and competence I release from
liability any and all individuals and organizations who provide information to AUBMC in good
faith and without malice concerning my professional competence background experience
ethics character utilization practice patterns health status and other qualifications for staff
appointment and clinical privileges and I consent to the release of such information
I acknowledge that I have the necessary credentials to request the attached privileges and
that I am mentally and physically capable of performing them To the best of my knowledge I
have no physical or behavioral conditions that have affected or may affect my ability to
perform the clinical privileges requested I hereby agree to undergo at any time upon request
a mental or physical examination satisfactory to AUBMC and if there is a mental or physical
impairment to provide evidence satisfactory to AUBMC that the impairment does not
interfere with my competence to provide care to patients
I pledge to maintain an ethical practice to provide for continuous care to my patients to
accept committee assignments to accept consultation and to participate in hospital
activities as assigned by the chairperson of the Department Specifically I pledge to abide by
the professional fees established by AUBMC not to receive from or pay another physician
I fully understand that the patient has the right to the confidentiality of hisher medical
information and that heshe has the right to approve or refuse the release of specific
information
I affirm that I am the person referred to in the foregoing application
Signature Date
Appendix 64 SQE-MST-002
SQE-MST-002 10 of 16
CODE OF ETHICS
Approved by the Medical Board on November 4 2003
The following principles should serve as a guide to ethical behavior for all Medical Staff
Medical Staff must recognize their responsibility not only to patients but also to society to
other medical and paramedical staff medical students and to themselves The following
principles are standards of conduct that define the essentials of honorable behavior for all
Medical Staff
1 - Medical Staff shall be dedicated to providing competent health care to all patients
with compassion and respect for human dignity
2 - Medical Staff shall deal honestly with patients and colleagues
3 - Medical Staff shall respect the rights of patients and of other Medical Staff
and shall safeguard patient confidences within the constraint of the law
4 - Medical Staff shall continue to study apply and advance scientific knowledge
make relevant information available to patients colleagues and to the public
obtain consultation and use the expertise of other Medical Staff when indicated
5 - Medical Staff shall respect the patientrsquos right to ask for a second opinion or the
transfer of his care to another physician
6 - Medical Staff who deem it necessary to transfer the care of a particular
patient to another Medical Staff member
A - The request shall be made to the Medical Staff member In case of
conflict it should be referred to division or department head
B - The Medical Staff member shall continue to provide the patient with
competent health care until such time as the patientrsquos care is transferred
to another Medical Staff member
7 - Medical Staff shall recognize that patients are best served by continuity of
health care and shall promote the coordination of care with other Medical teams
involved in the patientrsquos treatment
8 - Medical Staff shall not take financial advantage of patients and shall
adhere to the internal rules of professional fees
9 - Medical Staff shall recognize a responsibility to participate in activities
contributing to an improved community
10- Medical Staff shall abide by the University Policy on ldquoDuality or Conflict of Interestrdquo
11 - Medical Staff shall abide by the Lebanese Order of Physicians and the
Ministry of Health Codes on ethical behavior
Appendix 65
SQE-MST-002
SQE-MST-002 11 of 16
Appendix 66
SQE-MST-002
SQE-MST-002 12 of 16
SQE-MST-002 13 of 16
SQE-MST-002 14 of 16
SQE-MST-002 15 of 16
Appendix 67
SQE-MST-002
SQE-MST-002 16 of 16
CONFIDENTIALITY OF INFORMATION STATEMENT
I the undersigned do hereby declare and acknowledge that in connection
with and during my employment work training at the American University of
Beirut and its Medical Center (AUBAUBMC) I may have access to certain
information data materials documents and records in various forms written
verbal and computerized or otherwise (jointly referred to as the confidential
information) related to patient care research and financial data at AUBMC
As an employee of AUBMC it is my responsibility to maintain the confidentiality
of all such information
Additionally I understand that accessing patientsrsquo medical information stored
either in hard copies or in electronic form (Electronic health records include
but not limited to radiology laboratory other results medications and clinical
notes) is limited to my scope of work at AUBMC on the principle of need-to-
know basis
I understand that an audit trail noting my access to any of the above
information may be conducted and if Irsquom found to be in violation then
disciplinary action may be taken by the AUBAUBMC
I also declare and acknowledge that any violation of the foregoing will cause
AUBAUBMC immediate and irreparable harm that money cannot adequately
remedy and that AUBAUBMC shall be entitled to terminate my employment
work training in addition to obtaining any other remedies available at law
After my employment work training at AUBAUBMC regardless of the reason
for leaving I agree and undertake to abide by all AUBAUBMC confidentiality
rules and procedures and I will preserve and maintain all the information in
strict confidence and will not use disclose or in any other way divulge the
information except when authorized by AUBAUBMC
Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Appendix 68
SQE-MST-002
SQE-MST-002 7 of 16
PROFESSIONAL LIABILITY EXPLANATION FORM
This form must be completed if you answered ldquoyesrdquo to question 9 on page 13 of the Medical Staff Application
Form
Please complete this form for each pending or settled professional liability claim or lawsuit and any payment
made on behalf of applicant All questions must be answered completely If additional sheets are required please photocopy this page prior to completing Please provide us with a separate sheet for each malpractice claim or
lawsuit
Date of Alleged Incident helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date Claim Made or Suit Filed helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Patient Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Location of Incident helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Your Relationship to Patient (Attending Practitioner Surgeon Assistant Surgeon Consultant etc)
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Allegation helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Liability Carrier when Incident Occurred helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Additional Named Defendant(s) [if applicable] helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Status
1048576 Open ndash If open amount being sought$ helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
1048576 Closedndash If closed indicate method of closing 1048576Dismissal 1048576Settlement 1048576Judgement
Amount of Settlement of Judgment $helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Summary Summarize the circumstances giving rise to the matter If the matter involves patient care provide a narrative
describing your care and treatment of the patient If additional space is necessary attach adequate clinical detail
to allow proper evaluation by a committee of physicians Include (1) Condition and diagnosis at time of incident
(2) dates and description of treatment rendered (3) condition of patient subsequent to treatment and (4) other
relevant information Please print helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip helliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
SQE-MST-002 8 of 16
Signature (stamped signatures are not accepted) Date
Printed Name
SQE-MST-002 9 of 16
Attestations Acknowledgements and Release form
I fully understand that any significant misstatement(s) or omissions from this application
constitute cause for denial of appointment or cause for termination of appointment even
after recruitment to the Medical Staff at AUBMC I am also waiving any right of action or other
means of redress The information submitted by me in this application is true to the best of my
knowledge and belief I am willing to appear for interviews in regard to my application I
understand and agree that I as the applicant have the burden of producing adequate
information for proper evaluation of my application
I acknowledge that I have received and read the Bylaws Rules and Regulations for the
medical staff at AUBMC the policies relevant to the application process and generally to
clinical practice at the Medical Center and agree to be bound by the terms thereof in all
matters relating to staff membership and clinical privileges
By applying for appointment or reappointment to medical staff at AUBMC I hereby authorize
the Medical Staff Office to obtain information concerning my professional competence
character ethics and health to support my application I also authorize the release of this
information within AUBMC and to any of its affiliated Medical Centers The Medical Center
may use this information for any lawful purpose it deems appropriate
I consent to inspection by AUBMC its Medical Staff and their representatives of all documents
that may be material to an evaluation of my qualifications and competence I release from
liability any and all individuals and organizations who provide information to AUBMC in good
faith and without malice concerning my professional competence background experience
ethics character utilization practice patterns health status and other qualifications for staff
appointment and clinical privileges and I consent to the release of such information
I acknowledge that I have the necessary credentials to request the attached privileges and
that I am mentally and physically capable of performing them To the best of my knowledge I
have no physical or behavioral conditions that have affected or may affect my ability to
perform the clinical privileges requested I hereby agree to undergo at any time upon request
a mental or physical examination satisfactory to AUBMC and if there is a mental or physical
impairment to provide evidence satisfactory to AUBMC that the impairment does not
interfere with my competence to provide care to patients
I pledge to maintain an ethical practice to provide for continuous care to my patients to
accept committee assignments to accept consultation and to participate in hospital
activities as assigned by the chairperson of the Department Specifically I pledge to abide by
the professional fees established by AUBMC not to receive from or pay another physician
I fully understand that the patient has the right to the confidentiality of hisher medical
information and that heshe has the right to approve or refuse the release of specific
information
I affirm that I am the person referred to in the foregoing application
Signature Date
Appendix 64 SQE-MST-002
SQE-MST-002 10 of 16
CODE OF ETHICS
Approved by the Medical Board on November 4 2003
The following principles should serve as a guide to ethical behavior for all Medical Staff
Medical Staff must recognize their responsibility not only to patients but also to society to
other medical and paramedical staff medical students and to themselves The following
principles are standards of conduct that define the essentials of honorable behavior for all
Medical Staff
1 - Medical Staff shall be dedicated to providing competent health care to all patients
with compassion and respect for human dignity
2 - Medical Staff shall deal honestly with patients and colleagues
3 - Medical Staff shall respect the rights of patients and of other Medical Staff
and shall safeguard patient confidences within the constraint of the law
4 - Medical Staff shall continue to study apply and advance scientific knowledge
make relevant information available to patients colleagues and to the public
obtain consultation and use the expertise of other Medical Staff when indicated
5 - Medical Staff shall respect the patientrsquos right to ask for a second opinion or the
transfer of his care to another physician
6 - Medical Staff who deem it necessary to transfer the care of a particular
patient to another Medical Staff member
A - The request shall be made to the Medical Staff member In case of
conflict it should be referred to division or department head
B - The Medical Staff member shall continue to provide the patient with
competent health care until such time as the patientrsquos care is transferred
to another Medical Staff member
7 - Medical Staff shall recognize that patients are best served by continuity of
health care and shall promote the coordination of care with other Medical teams
involved in the patientrsquos treatment
8 - Medical Staff shall not take financial advantage of patients and shall
adhere to the internal rules of professional fees
9 - Medical Staff shall recognize a responsibility to participate in activities
contributing to an improved community
10- Medical Staff shall abide by the University Policy on ldquoDuality or Conflict of Interestrdquo
11 - Medical Staff shall abide by the Lebanese Order of Physicians and the
Ministry of Health Codes on ethical behavior
Appendix 65
SQE-MST-002
SQE-MST-002 11 of 16
Appendix 66
SQE-MST-002
SQE-MST-002 12 of 16
SQE-MST-002 13 of 16
SQE-MST-002 14 of 16
SQE-MST-002 15 of 16
Appendix 67
SQE-MST-002
SQE-MST-002 16 of 16
CONFIDENTIALITY OF INFORMATION STATEMENT
I the undersigned do hereby declare and acknowledge that in connection
with and during my employment work training at the American University of
Beirut and its Medical Center (AUBAUBMC) I may have access to certain
information data materials documents and records in various forms written
verbal and computerized or otherwise (jointly referred to as the confidential
information) related to patient care research and financial data at AUBMC
As an employee of AUBMC it is my responsibility to maintain the confidentiality
of all such information
Additionally I understand that accessing patientsrsquo medical information stored
either in hard copies or in electronic form (Electronic health records include
but not limited to radiology laboratory other results medications and clinical
notes) is limited to my scope of work at AUBMC on the principle of need-to-
know basis
I understand that an audit trail noting my access to any of the above
information may be conducted and if Irsquom found to be in violation then
disciplinary action may be taken by the AUBAUBMC
I also declare and acknowledge that any violation of the foregoing will cause
AUBAUBMC immediate and irreparable harm that money cannot adequately
remedy and that AUBAUBMC shall be entitled to terminate my employment
work training in addition to obtaining any other remedies available at law
After my employment work training at AUBAUBMC regardless of the reason
for leaving I agree and undertake to abide by all AUBAUBMC confidentiality
rules and procedures and I will preserve and maintain all the information in
strict confidence and will not use disclose or in any other way divulge the
information except when authorized by AUBAUBMC
Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Appendix 68
SQE-MST-002
SQE-MST-002 8 of 16
Signature (stamped signatures are not accepted) Date
Printed Name
SQE-MST-002 9 of 16
Attestations Acknowledgements and Release form
I fully understand that any significant misstatement(s) or omissions from this application
constitute cause for denial of appointment or cause for termination of appointment even
after recruitment to the Medical Staff at AUBMC I am also waiving any right of action or other
means of redress The information submitted by me in this application is true to the best of my
knowledge and belief I am willing to appear for interviews in regard to my application I
understand and agree that I as the applicant have the burden of producing adequate
information for proper evaluation of my application
I acknowledge that I have received and read the Bylaws Rules and Regulations for the
medical staff at AUBMC the policies relevant to the application process and generally to
clinical practice at the Medical Center and agree to be bound by the terms thereof in all
matters relating to staff membership and clinical privileges
By applying for appointment or reappointment to medical staff at AUBMC I hereby authorize
the Medical Staff Office to obtain information concerning my professional competence
character ethics and health to support my application I also authorize the release of this
information within AUBMC and to any of its affiliated Medical Centers The Medical Center
may use this information for any lawful purpose it deems appropriate
I consent to inspection by AUBMC its Medical Staff and their representatives of all documents
that may be material to an evaluation of my qualifications and competence I release from
liability any and all individuals and organizations who provide information to AUBMC in good
faith and without malice concerning my professional competence background experience
ethics character utilization practice patterns health status and other qualifications for staff
appointment and clinical privileges and I consent to the release of such information
I acknowledge that I have the necessary credentials to request the attached privileges and
that I am mentally and physically capable of performing them To the best of my knowledge I
have no physical or behavioral conditions that have affected or may affect my ability to
perform the clinical privileges requested I hereby agree to undergo at any time upon request
a mental or physical examination satisfactory to AUBMC and if there is a mental or physical
impairment to provide evidence satisfactory to AUBMC that the impairment does not
interfere with my competence to provide care to patients
I pledge to maintain an ethical practice to provide for continuous care to my patients to
accept committee assignments to accept consultation and to participate in hospital
activities as assigned by the chairperson of the Department Specifically I pledge to abide by
the professional fees established by AUBMC not to receive from or pay another physician
I fully understand that the patient has the right to the confidentiality of hisher medical
information and that heshe has the right to approve or refuse the release of specific
information
I affirm that I am the person referred to in the foregoing application
Signature Date
Appendix 64 SQE-MST-002
SQE-MST-002 10 of 16
CODE OF ETHICS
Approved by the Medical Board on November 4 2003
The following principles should serve as a guide to ethical behavior for all Medical Staff
Medical Staff must recognize their responsibility not only to patients but also to society to
other medical and paramedical staff medical students and to themselves The following
principles are standards of conduct that define the essentials of honorable behavior for all
Medical Staff
1 - Medical Staff shall be dedicated to providing competent health care to all patients
with compassion and respect for human dignity
2 - Medical Staff shall deal honestly with patients and colleagues
3 - Medical Staff shall respect the rights of patients and of other Medical Staff
and shall safeguard patient confidences within the constraint of the law
4 - Medical Staff shall continue to study apply and advance scientific knowledge
make relevant information available to patients colleagues and to the public
obtain consultation and use the expertise of other Medical Staff when indicated
5 - Medical Staff shall respect the patientrsquos right to ask for a second opinion or the
transfer of his care to another physician
6 - Medical Staff who deem it necessary to transfer the care of a particular
patient to another Medical Staff member
A - The request shall be made to the Medical Staff member In case of
conflict it should be referred to division or department head
B - The Medical Staff member shall continue to provide the patient with
competent health care until such time as the patientrsquos care is transferred
to another Medical Staff member
7 - Medical Staff shall recognize that patients are best served by continuity of
health care and shall promote the coordination of care with other Medical teams
involved in the patientrsquos treatment
8 - Medical Staff shall not take financial advantage of patients and shall
adhere to the internal rules of professional fees
9 - Medical Staff shall recognize a responsibility to participate in activities
contributing to an improved community
10- Medical Staff shall abide by the University Policy on ldquoDuality or Conflict of Interestrdquo
11 - Medical Staff shall abide by the Lebanese Order of Physicians and the
Ministry of Health Codes on ethical behavior
Appendix 65
SQE-MST-002
SQE-MST-002 11 of 16
Appendix 66
SQE-MST-002
SQE-MST-002 12 of 16
SQE-MST-002 13 of 16
SQE-MST-002 14 of 16
SQE-MST-002 15 of 16
Appendix 67
SQE-MST-002
SQE-MST-002 16 of 16
CONFIDENTIALITY OF INFORMATION STATEMENT
I the undersigned do hereby declare and acknowledge that in connection
with and during my employment work training at the American University of
Beirut and its Medical Center (AUBAUBMC) I may have access to certain
information data materials documents and records in various forms written
verbal and computerized or otherwise (jointly referred to as the confidential
information) related to patient care research and financial data at AUBMC
As an employee of AUBMC it is my responsibility to maintain the confidentiality
of all such information
Additionally I understand that accessing patientsrsquo medical information stored
either in hard copies or in electronic form (Electronic health records include
but not limited to radiology laboratory other results medications and clinical
notes) is limited to my scope of work at AUBMC on the principle of need-to-
know basis
I understand that an audit trail noting my access to any of the above
information may be conducted and if Irsquom found to be in violation then
disciplinary action may be taken by the AUBAUBMC
I also declare and acknowledge that any violation of the foregoing will cause
AUBAUBMC immediate and irreparable harm that money cannot adequately
remedy and that AUBAUBMC shall be entitled to terminate my employment
work training in addition to obtaining any other remedies available at law
After my employment work training at AUBAUBMC regardless of the reason
for leaving I agree and undertake to abide by all AUBAUBMC confidentiality
rules and procedures and I will preserve and maintain all the information in
strict confidence and will not use disclose or in any other way divulge the
information except when authorized by AUBAUBMC
Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Appendix 68
SQE-MST-002
SQE-MST-002 9 of 16
Attestations Acknowledgements and Release form
I fully understand that any significant misstatement(s) or omissions from this application
constitute cause for denial of appointment or cause for termination of appointment even
after recruitment to the Medical Staff at AUBMC I am also waiving any right of action or other
means of redress The information submitted by me in this application is true to the best of my
knowledge and belief I am willing to appear for interviews in regard to my application I
understand and agree that I as the applicant have the burden of producing adequate
information for proper evaluation of my application
I acknowledge that I have received and read the Bylaws Rules and Regulations for the
medical staff at AUBMC the policies relevant to the application process and generally to
clinical practice at the Medical Center and agree to be bound by the terms thereof in all
matters relating to staff membership and clinical privileges
By applying for appointment or reappointment to medical staff at AUBMC I hereby authorize
the Medical Staff Office to obtain information concerning my professional competence
character ethics and health to support my application I also authorize the release of this
information within AUBMC and to any of its affiliated Medical Centers The Medical Center
may use this information for any lawful purpose it deems appropriate
I consent to inspection by AUBMC its Medical Staff and their representatives of all documents
that may be material to an evaluation of my qualifications and competence I release from
liability any and all individuals and organizations who provide information to AUBMC in good
faith and without malice concerning my professional competence background experience
ethics character utilization practice patterns health status and other qualifications for staff
appointment and clinical privileges and I consent to the release of such information
I acknowledge that I have the necessary credentials to request the attached privileges and
that I am mentally and physically capable of performing them To the best of my knowledge I
have no physical or behavioral conditions that have affected or may affect my ability to
perform the clinical privileges requested I hereby agree to undergo at any time upon request
a mental or physical examination satisfactory to AUBMC and if there is a mental or physical
impairment to provide evidence satisfactory to AUBMC that the impairment does not
interfere with my competence to provide care to patients
I pledge to maintain an ethical practice to provide for continuous care to my patients to
accept committee assignments to accept consultation and to participate in hospital
activities as assigned by the chairperson of the Department Specifically I pledge to abide by
the professional fees established by AUBMC not to receive from or pay another physician
I fully understand that the patient has the right to the confidentiality of hisher medical
information and that heshe has the right to approve or refuse the release of specific
information
I affirm that I am the person referred to in the foregoing application
Signature Date
Appendix 64 SQE-MST-002
SQE-MST-002 10 of 16
CODE OF ETHICS
Approved by the Medical Board on November 4 2003
The following principles should serve as a guide to ethical behavior for all Medical Staff
Medical Staff must recognize their responsibility not only to patients but also to society to
other medical and paramedical staff medical students and to themselves The following
principles are standards of conduct that define the essentials of honorable behavior for all
Medical Staff
1 - Medical Staff shall be dedicated to providing competent health care to all patients
with compassion and respect for human dignity
2 - Medical Staff shall deal honestly with patients and colleagues
3 - Medical Staff shall respect the rights of patients and of other Medical Staff
and shall safeguard patient confidences within the constraint of the law
4 - Medical Staff shall continue to study apply and advance scientific knowledge
make relevant information available to patients colleagues and to the public
obtain consultation and use the expertise of other Medical Staff when indicated
5 - Medical Staff shall respect the patientrsquos right to ask for a second opinion or the
transfer of his care to another physician
6 - Medical Staff who deem it necessary to transfer the care of a particular
patient to another Medical Staff member
A - The request shall be made to the Medical Staff member In case of
conflict it should be referred to division or department head
B - The Medical Staff member shall continue to provide the patient with
competent health care until such time as the patientrsquos care is transferred
to another Medical Staff member
7 - Medical Staff shall recognize that patients are best served by continuity of
health care and shall promote the coordination of care with other Medical teams
involved in the patientrsquos treatment
8 - Medical Staff shall not take financial advantage of patients and shall
adhere to the internal rules of professional fees
9 - Medical Staff shall recognize a responsibility to participate in activities
contributing to an improved community
10- Medical Staff shall abide by the University Policy on ldquoDuality or Conflict of Interestrdquo
11 - Medical Staff shall abide by the Lebanese Order of Physicians and the
Ministry of Health Codes on ethical behavior
Appendix 65
SQE-MST-002
SQE-MST-002 11 of 16
Appendix 66
SQE-MST-002
SQE-MST-002 12 of 16
SQE-MST-002 13 of 16
SQE-MST-002 14 of 16
SQE-MST-002 15 of 16
Appendix 67
SQE-MST-002
SQE-MST-002 16 of 16
CONFIDENTIALITY OF INFORMATION STATEMENT
I the undersigned do hereby declare and acknowledge that in connection
with and during my employment work training at the American University of
Beirut and its Medical Center (AUBAUBMC) I may have access to certain
information data materials documents and records in various forms written
verbal and computerized or otherwise (jointly referred to as the confidential
information) related to patient care research and financial data at AUBMC
As an employee of AUBMC it is my responsibility to maintain the confidentiality
of all such information
Additionally I understand that accessing patientsrsquo medical information stored
either in hard copies or in electronic form (Electronic health records include
but not limited to radiology laboratory other results medications and clinical
notes) is limited to my scope of work at AUBMC on the principle of need-to-
know basis
I understand that an audit trail noting my access to any of the above
information may be conducted and if Irsquom found to be in violation then
disciplinary action may be taken by the AUBAUBMC
I also declare and acknowledge that any violation of the foregoing will cause
AUBAUBMC immediate and irreparable harm that money cannot adequately
remedy and that AUBAUBMC shall be entitled to terminate my employment
work training in addition to obtaining any other remedies available at law
After my employment work training at AUBAUBMC regardless of the reason
for leaving I agree and undertake to abide by all AUBAUBMC confidentiality
rules and procedures and I will preserve and maintain all the information in
strict confidence and will not use disclose or in any other way divulge the
information except when authorized by AUBAUBMC
Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Appendix 68
SQE-MST-002
SQE-MST-002 10 of 16
CODE OF ETHICS
Approved by the Medical Board on November 4 2003
The following principles should serve as a guide to ethical behavior for all Medical Staff
Medical Staff must recognize their responsibility not only to patients but also to society to
other medical and paramedical staff medical students and to themselves The following
principles are standards of conduct that define the essentials of honorable behavior for all
Medical Staff
1 - Medical Staff shall be dedicated to providing competent health care to all patients
with compassion and respect for human dignity
2 - Medical Staff shall deal honestly with patients and colleagues
3 - Medical Staff shall respect the rights of patients and of other Medical Staff
and shall safeguard patient confidences within the constraint of the law
4 - Medical Staff shall continue to study apply and advance scientific knowledge
make relevant information available to patients colleagues and to the public
obtain consultation and use the expertise of other Medical Staff when indicated
5 - Medical Staff shall respect the patientrsquos right to ask for a second opinion or the
transfer of his care to another physician
6 - Medical Staff who deem it necessary to transfer the care of a particular
patient to another Medical Staff member
A - The request shall be made to the Medical Staff member In case of
conflict it should be referred to division or department head
B - The Medical Staff member shall continue to provide the patient with
competent health care until such time as the patientrsquos care is transferred
to another Medical Staff member
7 - Medical Staff shall recognize that patients are best served by continuity of
health care and shall promote the coordination of care with other Medical teams
involved in the patientrsquos treatment
8 - Medical Staff shall not take financial advantage of patients and shall
adhere to the internal rules of professional fees
9 - Medical Staff shall recognize a responsibility to participate in activities
contributing to an improved community
10- Medical Staff shall abide by the University Policy on ldquoDuality or Conflict of Interestrdquo
11 - Medical Staff shall abide by the Lebanese Order of Physicians and the
Ministry of Health Codes on ethical behavior
Appendix 65
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Appendix 66
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SQE-MST-002 15 of 16
Appendix 67
SQE-MST-002
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CONFIDENTIALITY OF INFORMATION STATEMENT
I the undersigned do hereby declare and acknowledge that in connection
with and during my employment work training at the American University of
Beirut and its Medical Center (AUBAUBMC) I may have access to certain
information data materials documents and records in various forms written
verbal and computerized or otherwise (jointly referred to as the confidential
information) related to patient care research and financial data at AUBMC
As an employee of AUBMC it is my responsibility to maintain the confidentiality
of all such information
Additionally I understand that accessing patientsrsquo medical information stored
either in hard copies or in electronic form (Electronic health records include
but not limited to radiology laboratory other results medications and clinical
notes) is limited to my scope of work at AUBMC on the principle of need-to-
know basis
I understand that an audit trail noting my access to any of the above
information may be conducted and if Irsquom found to be in violation then
disciplinary action may be taken by the AUBAUBMC
I also declare and acknowledge that any violation of the foregoing will cause
AUBAUBMC immediate and irreparable harm that money cannot adequately
remedy and that AUBAUBMC shall be entitled to terminate my employment
work training in addition to obtaining any other remedies available at law
After my employment work training at AUBAUBMC regardless of the reason
for leaving I agree and undertake to abide by all AUBAUBMC confidentiality
rules and procedures and I will preserve and maintain all the information in
strict confidence and will not use disclose or in any other way divulge the
information except when authorized by AUBAUBMC
Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Appendix 68
SQE-MST-002
SQE-MST-002 11 of 16
Appendix 66
SQE-MST-002
SQE-MST-002 12 of 16
SQE-MST-002 13 of 16
SQE-MST-002 14 of 16
SQE-MST-002 15 of 16
Appendix 67
SQE-MST-002
SQE-MST-002 16 of 16
CONFIDENTIALITY OF INFORMATION STATEMENT
I the undersigned do hereby declare and acknowledge that in connection
with and during my employment work training at the American University of
Beirut and its Medical Center (AUBAUBMC) I may have access to certain
information data materials documents and records in various forms written
verbal and computerized or otherwise (jointly referred to as the confidential
information) related to patient care research and financial data at AUBMC
As an employee of AUBMC it is my responsibility to maintain the confidentiality
of all such information
Additionally I understand that accessing patientsrsquo medical information stored
either in hard copies or in electronic form (Electronic health records include
but not limited to radiology laboratory other results medications and clinical
notes) is limited to my scope of work at AUBMC on the principle of need-to-
know basis
I understand that an audit trail noting my access to any of the above
information may be conducted and if Irsquom found to be in violation then
disciplinary action may be taken by the AUBAUBMC
I also declare and acknowledge that any violation of the foregoing will cause
AUBAUBMC immediate and irreparable harm that money cannot adequately
remedy and that AUBAUBMC shall be entitled to terminate my employment
work training in addition to obtaining any other remedies available at law
After my employment work training at AUBAUBMC regardless of the reason
for leaving I agree and undertake to abide by all AUBAUBMC confidentiality
rules and procedures and I will preserve and maintain all the information in
strict confidence and will not use disclose or in any other way divulge the
information except when authorized by AUBAUBMC
Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Appendix 68
SQE-MST-002
SQE-MST-002 12 of 16
SQE-MST-002 13 of 16
SQE-MST-002 14 of 16
SQE-MST-002 15 of 16
Appendix 67
SQE-MST-002
SQE-MST-002 16 of 16
CONFIDENTIALITY OF INFORMATION STATEMENT
I the undersigned do hereby declare and acknowledge that in connection
with and during my employment work training at the American University of
Beirut and its Medical Center (AUBAUBMC) I may have access to certain
information data materials documents and records in various forms written
verbal and computerized or otherwise (jointly referred to as the confidential
information) related to patient care research and financial data at AUBMC
As an employee of AUBMC it is my responsibility to maintain the confidentiality
of all such information
Additionally I understand that accessing patientsrsquo medical information stored
either in hard copies or in electronic form (Electronic health records include
but not limited to radiology laboratory other results medications and clinical
notes) is limited to my scope of work at AUBMC on the principle of need-to-
know basis
I understand that an audit trail noting my access to any of the above
information may be conducted and if Irsquom found to be in violation then
disciplinary action may be taken by the AUBAUBMC
I also declare and acknowledge that any violation of the foregoing will cause
AUBAUBMC immediate and irreparable harm that money cannot adequately
remedy and that AUBAUBMC shall be entitled to terminate my employment
work training in addition to obtaining any other remedies available at law
After my employment work training at AUBAUBMC regardless of the reason
for leaving I agree and undertake to abide by all AUBAUBMC confidentiality
rules and procedures and I will preserve and maintain all the information in
strict confidence and will not use disclose or in any other way divulge the
information except when authorized by AUBAUBMC
Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Appendix 68
SQE-MST-002
SQE-MST-002 13 of 16
SQE-MST-002 14 of 16
SQE-MST-002 15 of 16
Appendix 67
SQE-MST-002
SQE-MST-002 16 of 16
CONFIDENTIALITY OF INFORMATION STATEMENT
I the undersigned do hereby declare and acknowledge that in connection
with and during my employment work training at the American University of
Beirut and its Medical Center (AUBAUBMC) I may have access to certain
information data materials documents and records in various forms written
verbal and computerized or otherwise (jointly referred to as the confidential
information) related to patient care research and financial data at AUBMC
As an employee of AUBMC it is my responsibility to maintain the confidentiality
of all such information
Additionally I understand that accessing patientsrsquo medical information stored
either in hard copies or in electronic form (Electronic health records include
but not limited to radiology laboratory other results medications and clinical
notes) is limited to my scope of work at AUBMC on the principle of need-to-
know basis
I understand that an audit trail noting my access to any of the above
information may be conducted and if Irsquom found to be in violation then
disciplinary action may be taken by the AUBAUBMC
I also declare and acknowledge that any violation of the foregoing will cause
AUBAUBMC immediate and irreparable harm that money cannot adequately
remedy and that AUBAUBMC shall be entitled to terminate my employment
work training in addition to obtaining any other remedies available at law
After my employment work training at AUBAUBMC regardless of the reason
for leaving I agree and undertake to abide by all AUBAUBMC confidentiality
rules and procedures and I will preserve and maintain all the information in
strict confidence and will not use disclose or in any other way divulge the
information except when authorized by AUBAUBMC
Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Appendix 68
SQE-MST-002
SQE-MST-002 14 of 16
SQE-MST-002 15 of 16
Appendix 67
SQE-MST-002
SQE-MST-002 16 of 16
CONFIDENTIALITY OF INFORMATION STATEMENT
I the undersigned do hereby declare and acknowledge that in connection
with and during my employment work training at the American University of
Beirut and its Medical Center (AUBAUBMC) I may have access to certain
information data materials documents and records in various forms written
verbal and computerized or otherwise (jointly referred to as the confidential
information) related to patient care research and financial data at AUBMC
As an employee of AUBMC it is my responsibility to maintain the confidentiality
of all such information
Additionally I understand that accessing patientsrsquo medical information stored
either in hard copies or in electronic form (Electronic health records include
but not limited to radiology laboratory other results medications and clinical
notes) is limited to my scope of work at AUBMC on the principle of need-to-
know basis
I understand that an audit trail noting my access to any of the above
information may be conducted and if Irsquom found to be in violation then
disciplinary action may be taken by the AUBAUBMC
I also declare and acknowledge that any violation of the foregoing will cause
AUBAUBMC immediate and irreparable harm that money cannot adequately
remedy and that AUBAUBMC shall be entitled to terminate my employment
work training in addition to obtaining any other remedies available at law
After my employment work training at AUBAUBMC regardless of the reason
for leaving I agree and undertake to abide by all AUBAUBMC confidentiality
rules and procedures and I will preserve and maintain all the information in
strict confidence and will not use disclose or in any other way divulge the
information except when authorized by AUBAUBMC
Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Appendix 68
SQE-MST-002
SQE-MST-002 15 of 16
Appendix 67
SQE-MST-002
SQE-MST-002 16 of 16
CONFIDENTIALITY OF INFORMATION STATEMENT
I the undersigned do hereby declare and acknowledge that in connection
with and during my employment work training at the American University of
Beirut and its Medical Center (AUBAUBMC) I may have access to certain
information data materials documents and records in various forms written
verbal and computerized or otherwise (jointly referred to as the confidential
information) related to patient care research and financial data at AUBMC
As an employee of AUBMC it is my responsibility to maintain the confidentiality
of all such information
Additionally I understand that accessing patientsrsquo medical information stored
either in hard copies or in electronic form (Electronic health records include
but not limited to radiology laboratory other results medications and clinical
notes) is limited to my scope of work at AUBMC on the principle of need-to-
know basis
I understand that an audit trail noting my access to any of the above
information may be conducted and if Irsquom found to be in violation then
disciplinary action may be taken by the AUBAUBMC
I also declare and acknowledge that any violation of the foregoing will cause
AUBAUBMC immediate and irreparable harm that money cannot adequately
remedy and that AUBAUBMC shall be entitled to terminate my employment
work training in addition to obtaining any other remedies available at law
After my employment work training at AUBAUBMC regardless of the reason
for leaving I agree and undertake to abide by all AUBAUBMC confidentiality
rules and procedures and I will preserve and maintain all the information in
strict confidence and will not use disclose or in any other way divulge the
information except when authorized by AUBAUBMC
Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Appendix 68
SQE-MST-002
SQE-MST-002 16 of 16
CONFIDENTIALITY OF INFORMATION STATEMENT
I the undersigned do hereby declare and acknowledge that in connection
with and during my employment work training at the American University of
Beirut and its Medical Center (AUBAUBMC) I may have access to certain
information data materials documents and records in various forms written
verbal and computerized or otherwise (jointly referred to as the confidential
information) related to patient care research and financial data at AUBMC
As an employee of AUBMC it is my responsibility to maintain the confidentiality
of all such information
Additionally I understand that accessing patientsrsquo medical information stored
either in hard copies or in electronic form (Electronic health records include
but not limited to radiology laboratory other results medications and clinical
notes) is limited to my scope of work at AUBMC on the principle of need-to-
know basis
I understand that an audit trail noting my access to any of the above
information may be conducted and if Irsquom found to be in violation then
disciplinary action may be taken by the AUBAUBMC
I also declare and acknowledge that any violation of the foregoing will cause
AUBAUBMC immediate and irreparable harm that money cannot adequately
remedy and that AUBAUBMC shall be entitled to terminate my employment
work training in addition to obtaining any other remedies available at law
After my employment work training at AUBAUBMC regardless of the reason
for leaving I agree and undertake to abide by all AUBAUBMC confidentiality
rules and procedures and I will preserve and maintain all the information in
strict confidence and will not use disclose or in any other way divulge the
information except when authorized by AUBAUBMC
Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Signature helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Date helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip
Appendix 68
SQE-MST-002