Physicians planning on brining staff to any of the MGHS Campuses

Date Submitted: 11/21/2009

JCAHO regulations require that employers be made aware of any non-MGH employees who provide care or treatment within their facility. To this end, we ask the following:

Do any of the physicians, or limited licensed practitioners in your office, bring any of your non-credentialed staff on to the MGH campuses to provide care or treatment of patients?

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	Doctor submitting request:
	Name of individual:
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	Date:
	Doctor submitting request:
	Name of individual:
	Title of individual:
	Date:
	Doctor submitting request:
	Name of individual:
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	Date: