TO REQUEST AN APPLICATION FOR PRIVILEGES:

Thank you for your interest in joining the Medical Staff of Summit Surgical Center, LLC. To begin the process, please send an e-mail to Karen Paladino Credentials Assistant, at [email protected] and include the following information.

• Your full name
• Your e-mail address (to ensure we are able to respond to your request)
• Your street address, city, state & zip
• Your phone and fax number
• The medical specialty privileges for which you wish to apply

Once the e-mail request is received, the Medical Staff Office will respond with an e-mail to the address you have designated. That e-mail will include our medical staff application, any specialty privilege applications that you have requested and instructions on how to complete the process.

As part of the application process you will be asked to acknowledge that you have been furnished with a copy of the Medical Staff Bylaws Rules and Regulations, and agree to be bound by them.

For Physician Offices:

Below are some frequently requested forms:

• Scheduling Form for Physician Offices
• Physician Time off - Scheduling form
• Surgical Scheduling Change Form
• Add-on Information
• Surgical History and Physical Form
• Consent to Procedure (Surgical Consent)
• Preoperative Nourishment Instructions
• BMI Table
• Pre-Op Prophylaxis Order Form

Patient Brochures and Information:

• • Includes the following:
    • Summit Surgical Center Notice of our Patient's Bill of Rights and Responsibilities
    • Advanced Directive Policy Information
    • Summit Surgical Center, LLC Notice of Physician Ownership
    • Pre-operative Nourishment Instructions
    • "Speak Up:  How to Make Your Surgery Safer" Information
    • Joint Notice of Privacy Practices
    • Directions
• Important Advance Information
• Patient's Bill of Rights and Responsibilities
• Patient's Bill of Rights and Responsibilities in Spanish
• Advanced Directives Notice
• Acknowledgement of receipt patient information: You may print this form and fax to 856-247-7874 - Attn: PAT Dept.

Reference Materials:

• Nomad Pro Operator Manual