Medical Staff Services Use Only:

Provider ID

Medical Staff Services Trainees Registration Form

□ Medical Student ☐ SRNA Student ☐ PA Student ☐Other:
□ Resident ☐ Fellow ☐ PGY
Applicable to Residents & Fellows Only:
TX Permit #: Expiration Date: NPI #:
DEA #: Expiration Date: DPS #: Expiration Date:

Have you ever worked at any Harris Health System facility prior to this time? ☐ YES ■ NO
☐
If yes, what was your Harris Health Provider ID#:

Medical School Affiliation ☐BCM ☐UTH

■
☐Other
Clinical Specialty Otolaryngology Clinical Department Otolaryngology - Ibrahim Alava III
Anticipated Program Start Date 10/14/2020 Anticipated Program Completion Date 1/18/2020

First Name Middle Name Last Name Suffix

Carolyn Ko Fan
Maiden Name Aliases by Which You Have Been Known Marital Status
Single
Social Security Number Date of Birth Gender
027-80-9944 06/04/1997 Female
Social Security Number Disclosure Notice (5 U.S.C. §552a Section 7): It is mandatory that you provide your Social Security Number to Harris Health System. Harris Health System does not employ, retain or
engage in business relationships with individuals and entities that have been convicted of certain criminal violations or have been the subject of sanctioning, debarment, exclusion, or other adverse action by an appropriate
enforcement or regulatory agency of the federal or state government. Your Social Security Number will be stored by Harris Health System and provided to a third‐party vendor on a monthly basis to screen you against
various databases to determine whether you have been the subject of any of the actions described in the preceding sentence. See Harris Health System Policy 3.35, Screening for Ineligible Persons, for further information
and authority.

Local Street Address City State Zip

7900 Cambridge St. Apt 24-1A Houston Tx 77054
Permanent Street Address (If Different from Local Address) City State Zip

Professional Degree Institution Awarded By Date Graduated

BSA University of Texas 12/2018

Home Telephone # Cell Phone # Pager # E‐mail Address

361-834-8266 361-834-8266 [email protected]

Emergency Contact Information

Name Betty Fan Relationship Mother
Phone Number 3617283556 Alternate Phone Number 3618539803
I hereby authorize the Harris Health System Medical Staff Services to utilize the information herein and input into the Medical Staff Service data base as required.
I understand that this information is for EPIC/Network access and IT Education pertinent to my medical educational rotation only. This information will be held
confidential.
Signature: Carolyn Fan Date: 10/9/2020
Digitally signed by Carolyn Fan
Date: 2020.10.09 10:39:39 -05'00'

284459 / 08.18
 HEALTH/IMMUNIZATION QUESTIONNAIRE
Completion of this form will meet most information requirements of the Harris Health System and its Medical Staff. It must be completed in its entirety and
honestly. Should need for additional explanation be needed, appropriate space is provided at the end of each section. When doing so, reference the particular
question by number.

HEALTH STATUS
To answer this question appropriately, you must report any condition which affects your motor skills or cognitive ability or judgment; or,
which may adversely affect your ability to care for patients or to interact appropriately with caregivers.
1) Do you currently have or have you ever had a physical or mental health condition which has affected or would affect your
ability to exercise clinical privileges; or, would require an accommodation in order for you to exercise the privilege(s) you
have requested safely and competently? Yes ■ No
2) Have you ever or are currently engaged in the unlawful use of drugs? Yes ■ No
3) Have you ever had or do you now have an alcohol consumption problem? Yes ■ No

If you have answered yes to any of the questions above, please explain in the space below. If you answered “yes” to either
Question 2 or 3, you must identify and describe any rehabilitation program in which you are currently enrolled or have been
enrolled, which assures abstinence prospectively and your adherence to prevailing standards of professional performance;
and/or, assures, if appropriate, that alcohol consumption will not interfere with your practice of medicine, patient care
responsibilities or adherence to prevailing standards of professional performance.

TB STATUS and IMMUNIZATIONS

1. TB Status: Harris Health System requires all faculty and healthcare providers to remain current with yearly TB testing.

■ I attest that I have had a TB skin test within the past twelve (12) month and the results have found to be negative.
or
I attest that I have had a TB skin test with positive results, followed by a negative CXR and I have no symptoms of active
disease.
or
I attest that I currently have TB symptoms that are under treatment. I have attached appropriate documentation.
(If you checked here, you must give a full explanation in the space provided at the end of this section.)

2. Have you ever had Chickenpox or the Varicella (Chickenpox) vaccine? ■ Yes No

3. Have you had Measles, Mumps or Rubella or the MMR vaccine? ■ Yes No

4. Have you had Hepatitis B or the HepB vaccine? ■ Yes No

5. Have you had a Tetanus booster within 10 years or the Tetanus-Diphtheria-Pertussis (Tdap) vaccine?
■ Yes No

6. Have you had an influenza vaccine within the past 12 months? ■ Yes No If yes, provide date: 10/2020 (mm/yy)
*Proof of Flu-vaccine or approved exemption is required for the current Flu Season (November 1-April 30).

Please clarify any additional information pertinent to your current health and/or immunization status in the space below:

Carolyn Fan
Signature Printed Name

10/9/2020
Date
284457 / 08.18
 Certificate Compliance Form
As part of your application with the Harris Health System, you must initial each item acknowledging that you have read
and understand the information presented to you and return with your application. Your name, signature, and date are
required at the bottom of this form.
CF 1. I have read and understand the enclosed Harris Health System Code of Conduct. I understand that compliance
with this Code is a condition to my ability to practice my profession at Harris Health System. I further
understand that violation of the Code may result in disciplinary action as provided in the Bylaws of the Medical
Staff.
CF 2. I have read and understand the enclosed Deficit Reduction Act policy and will abide by it.
CF 3. I have read and understand the enclosed Reporting Fraud and Abuse, Wrongdoing and Non‐Retaliation policy
and abide by it.
CF 4. I am not currently excluded, debarred, suspended, or otherwise ineligible to participate in the Federal health
care programs or Federal procurement and non‐procurement programs.
CF 5. I have not been convicted of a criminal offense, expecting or awaiting the exclusion, debarment, suspension
or otherwise being declared ineligible.
CF 6. I am not on the General Services Administration’s List of Parties Excluded from Federal Health Care
Programs/EPLS (available on the Internet at (http://exclusions.oig.hhs.gov/), or the HHS/OIG List of Excluded
Individuals/Entities (LEIE) (available through the Internet at http://oig.hhs.gov).
CF 7. I will disclose immediately any debarment, exclusion, suspension, or any other event that makes me ineligible
to participate in Federal health care programs or Federal procurement or non‐procurement programs to
Harris Health System Medical Staff Services Department and the Harris Health System Corporate Compliance
Officer.
CF 8. I understand that Harris Health System conducts annual screenings to monitor whether Medical Staff
members are on exclusions and debarment lists, such as the OIG/LEIE and EPLS lists, will remove Medical Staff
members that are found to be excluded or debarred from business operations related to Federal health care
programs or services related to compensation through such programs.
CF 9. I have received a copy of the materials that are used by Harris Health System for the annual compliance
training.
CF 10. I will disclose any conflict of interest that I may have related to any ownership interest and/or other
relationships that are or may appear to be in conflict with my responsibilities to Harris Health System to
Medical Staff Services and the Harris Health System Corporate Compliance Officer.
CF 11. I understand that Medical Staff members should avoid conflict of interest related to their Medical Staff
duties. I also understand that unavoidable conflicts should be disclosed and the Medical Staff member
should not participate in any discussion, decision, or activity connected with the conflict.

The forgoing is true and correct to the best of my knowledge:

Carolyn Fan
Printed Name Provider ID# Service
10/9/2020
Signature Date

284458 / 08.18
 Certification and Acknowledgement
I acknowledge and certify that I have received and read Harris Health’s Code of Conduct (Code), understand my
obligations to comply with the Code, and have an affirmative duty to report compliance violations.

I agree to comply with the Code.

Print your name here:

Carolyn Fan

Please sign here:

10/9/2020
ID # Date:

16
 Harris Health Experience Commitment Statement

ServiceFIRST Interaction Standards

To ensure that I deliver an Exceptional Harris Health Experience with every interaction with
patients, guests, and co-workers, I commit to exhibiting these specific behaviors:

FRIENDLINESS: Friendly, helpful greeting

“Welcome to Harris Health, my name is…, how may I help you?”
“Good morning, my name is Jane Smith, I look forward to taking care of you.”
“Thank you for calling Harris Health, this is...how can I help you?”

INTEGRITY: “I” statements to show ownership

“I can help you with …”
“I will get someone who can help you with …”
“Is there anything I can do for you?”

RESPONSIBLITIY: Responsible for time expectations and next steps

Reset time expectations
Keep patients and coworkers informed
Describe and communicate next steps

SATISFACTION: Surroundings and personal appearance

Personal appearance: name badge on the upper part of your body, no lanyard
Adhere to dress code standards
Keep work areas/public areas clean and clutter free

TEAMWORK: Thank You

“Thank you for choosing Harris Health.”
“Thank you for letting us take care of you.”
“Thank you and have a healthy day.”

I have read and understand my commitment and acknowledge that it is a standard for how those in our
care shall be treated. I agree to follow the interaction standards listed above and deliver quality care and
service to our patients. I understand that I am accountable for consistently exhibiting these behaviors.

10/9/2020
Signature Employee ID # Date
 Practitioner/Researcher Acceptable User Agreement
(Practitioners/Researchers requesting access to Harris Health System information systems MUST read and SIGN this form)

First Name Middle Name Last Name Suffix

Title Department

Medical School Affiliation ☐ BCM ☐ UTH ☐ Other _______________________

E-mail Address assigned by School Affiliation

I understand and agree that I shall use the information systems for Harris Health System for business purposes and:
1. I understand that any types of patient identifiable information as well as other types of business information are
confidential. I will follow all applicable Harris Health policies to protect confidential and other types of information utilized
in the course of Harris Health business that is created, maintained, or transmitted in any form (i.e. oral, written, or
electronic) whether company developed or obtained from outside sources.
2. I understand that I am responsible for complying with all HIPAA Privacy and Security Policies.
3. I am aware that the data I create on Harris Health information systems remains the property of Harris Health.
4. I will not engage in any activity that is illegal under local, state, federal or international law while utilizing Harris Health-
owned resources.
5. I will not disable Anti-Virus or Anti-Spyware and I will not download or install applications without written approval of the
Information Security Department (InfoSec).
6. I will not install any hardware or network devices without written approval from InfoSec.
7. I will not remove electronic Protected Health Information (ePHI) from Harris Health facilities without written approval
from my supervisor or such other approval as may be required by District policy.
8. I will not take photographs of patients or PHI/ePHI without written approval of the patient and my supervisor or PSA.
9. All approvals must be documented in writing (via e-mail) and on file with Harris Health IT Security Management Office.
10. I will use only my assigned user ID/Password to access Harris Health Information Resources whether at Harris
Health facilities or accessing them remotely. I will protect my Password from use by others.
11. I will create a “hard to guess” password and notify IT if I think my Password has been compromised.
12. I will be accountable for any orders or data entered into the system under my ID and password.
13. I will use encryption to send ePHI via e-mail outside Harris Health.
14. I will not send unsolicited bulk emails (spam) or chain letters.
15. I will physically and logically secure all transportable devices and media that contain ePHI.
16. I will report Security Incidents to 800-500-0333, 713-566-6097 or 713-566-4344 or via e-mail to [email protected].
17. I will call 713-566-4344 or e-mail [email protected] if I am unclear about how to handle a situation with regards to
security.
18. I realize that I should have no expectation of privacy in my work-related conduct or the use of Harris Health owned or Harris
Health provided equipment or supplies.
19. I also realize that Harris Health management reserves the right to examine electronic mail messages, files on personal
computers, web browser cache files, web browser bookmarks, logs of web sites visited, computer system
configurations, and other information stored on or passing through Harris Health computers.
20. I am aware Harris Health routinely logs the web sites visited, files downloaded, time spent on the Internet, emails
and related information.
21. I may use the Harris Health information systems for limited personal use. I understand, however, that use of Harris
Health information systems for personal use may subject me to disciplinary action if such use interferes with my job
duties, involves conducting a private business on Harris Health time, or becomes excessive.
22. I realize that failure to comply with these statements and Harris Health HIPAA Privacy and Security policies and
procedures may result in disciplinary action as described in the HIPAA Sanctions Policy (3.11.104)

SIGNATURE: Date:
Printed versions of this document are uncontrolled. Please go to the Harris Health Document Control Center to retrieve an official controlled version of the document.
https://apps.hchd.local/sites/dcc 284792 (9.19)
 SCRUB STATION SYSTEM USER APPLICATION
(To be completed by Applicant, authorized by Department Manager, and returned to Linen Manager.)

Last Name: Fan

First Name: Carolyn

Middle Initial: K

Please circle: Baylor – BT / UT - LBJ

Service:

Job Title / Designation: Medical Student

Harris Health System Badge Number:

Preferred Scrub Size (check one top and one pant size only)
Tops: Small X Pants: Small X

Medium Medium
Large Large
X-Large X-Large
2X-Large 2X-Large
3X-Large 3X-Large

Number of Sets 2
(Maximum of 2 sets of scrubs per applicant)

Security and Abuse of the System:

1. Each authorized user is responsible for the control of their account, including financial responsibility
for theft, sharing, loaning, or other use of access information.

2. Any type of abuse of the system will result in termination of access to the system and the individual must pay for all
attire not returned. The term abuse is classified but not limited to throwing foreign materials (other colored clothing,
paper scrub apparel, towels, and trash) into the return system, attempting to falsify a transaction, and vandalism. The
return system is equipped with electronic surveillance equipment designed to detect abuse.

By signing this document, you are agreeing to abide by procedure set forth by the Harris Health System for the use of the
Scrub Station system.

Applicant: Authorizing Manager / Medical Staff Services:

Signature Signature

Date 10/9/2020 Date

Printed copies of this document are uncontrolled. In the case of a conflict between printed and electronic versions of this document, the controlled version
published on the Harris Health System Document Control Center prevails.
284612 │ 11.17
 Harris Health System Ambulatory Pharmacy
Substitution Authorization

I grant approval for pharmacists within Harris Health System ambulatory pharmacies (Class A
pharmacies) to perform the following medication substitutions:

• Substitution of a brand-name drug for the equivalent generic drug;

• Substitution of one strength for an equivalent strength and dose (for example, if a provider
prescribes atenolol 100mg – take 1 tab PO daily, the pharmacist may dispense atenolol 50mg
– take 2 tabs PO daily); and
• Substitution of a drug to another therapeutically comparable drug and dose in the same class,
if approved by the Medical Staff Pharmacy and Therapeutics Committee and the Medical
Executive Board (for example, fluticasone for mometasone).

The Pharmacy shall maintain and publish a list of therapeutic comparable substitutions approved by
the Medical Staff Pharmacy and Therapeutics Committee and the Medical Executive Board. The P&T
and MEB approved therapeutic interchange list (substitution list) will be made available on the Harris
Health intranet.

I acknowledge that if I, as a prescriber, desire that a prescription not be subject to the medication
substitution process described above, I have been advised to use the Non-Formulary Request Process
as detailed in Policy 500.00, Drug Formulary.

For all trainees (Fellows and Residents) practicing within the Harris Health System, this therapeutic
interchange authorization shall be valid throughout the duration of the training program.

Date: ___________________ Print Name: ________________________________________________________________

Texas Medical License #: ___________________________ DEA #: _____________________________________________

DPS #: _________________ NPI #: __________________________ Harris Health Provider ID #: _____________________

Service Area/Specialty: __________________________________ Pager #: _____________________________________

Signature: _____________________________________________

Please check all that apply: □ BT □ LBJ □ ACS □ Ambulatory Surgical Center

For Medical Staff Services Only: This form must be signed by the provider (except trainees) every 2 years for Harris Health System ambulatory
pharmacies to meet Texas State Board of Pharmacy rules and regulations.
harrishealth.org

Revised: 5.9.2017 284484 | 10.18