MINISTRY OF HEALTH

General Directorate of Health Affairs in Riyadh Region

CREDENTIALING APPLICATION
DIRECTION
PLEASE:
 Complete this entire application
 Hand writing will not be acceptable
 Curriculum vitae will not be accepted as replacement for a part of this application.
 Submit a copy and retain the original for your records.
 Sign and date: attestation on page 5 and / or 6
 Sign and date: release of information on page 6
PERSONAL INFORMATION
Professional Title
First Name Middle Name Last Name
MICHELLE MANGUIAT MAGSINO
Gender Date of Birth (m/d/y) Citizenship / Place of Birth
 Male  Female 1988/ 15 / 06 FILIPINO / PHILIPPINES
ID / IQAMA Number Expiry Date (m/d/y) Place of Issue

Address Mabini Lipa City Batangas Philippines 319

City Postal Code p . o . box
Lipa 4217 N/A

1 Telephone No. ( work )

N/A
Telephone No. ( home )
N/A
.Fax No
N/A
.Mobile No Official Email ( MOH ) Alternate Email
0500795092 michellemagsino66@gmail.com
PROFESSIONAL INFORMATION
Hospital Name Job Number
AL IMAM ABDULRAHMAN AL FAISAL HOSPITAL 33485/30
Date of Employment (m/d/y) Contact End Date (m/d/y) if applicable
05/30/1438 N/A
EDUCATION
List all training attended. Enclose copies of your certificates, if additional training to what is requested below has been completed, please attach on a
separate form
Medical / Professional School
Name LIPA CITY COLLEGES
City Country Postal Code
LIPA PHILIPPINES 4217
Degree Year of Graduation Dates Attended (m/y)
BACHELOR OF SCIENCE IN NURSING 2008 2008 —2004
Internship N/A
Hospital Name
City Country Postal Code

?Program Successfully Completed Attendance Date (m/y)

 Yes  No
Program specialty Program Director .Telephone No
MEDICINE/SURGERY/PEADIATRIC/OBS AND
MINISTRY OF HEALTH
GYN
Residency N/A
Hospital Name
City Country Postal Code

?Program Successfully Completed Attendance Date (m/y)

 Yes  No
Program specialty Program Director .Telephone No
 Fellowship N/A
Hospital Name
City Country Postal Code

?Program Successfully Completed Attendance Date (m/y)

 Yes  No ----/-- From --/---- to
Program specialty Program Director .Telephone No

Teaching Appointment N/A

Hospital Name
City Country Postal Code

?Program Successfully Completed Attendance Date (m/y)

 Yes  No ----/-- From --/---- to
Program specialty Program Director .Telephone No

Others N/A
Hospital Name
City Country Postal Code

?Program Successfully Completed Attendance Date (m/y)

 Yes  No ----/-- From --/---- to
Program specialty Program Director .Telephone No

CERTIFICATE & LICENSES

Certification – Enclose copies of your certificates (Board, Master, PH, etc.)
Certificate Place of ISSUE Date of Issue (m /y) Expiry Date (m/y)

2
BOARD CERTIFICATE IN
PHILIPPINES 09/2008 N/A
NURISNG
---- / -- / --
---- / -- / -- ---- / -- / --
---- / -- / -- ---- / -- / --
---- / -- / -- ---- / -- / --
---- / -- / -- ---- / -- / --
Saudi Commission For Health Specialties Registration
SCHS (specialty) SCHS Number Date of Issue (m /y) Expiry Date (m/y)

Professional Licenses – Enclose copies of your certificates (BLS, ACLS, etc.)

Professional Licenses Type Expiry Date (m/y)
BLS Instructor Provider 09/2017
Instructor Provider ----/--/--
Instructor Provider ---- / -- / --
Instructor Provider ---- / -- / --
Instructor Provider ---- / -- / --
WORK HISTORY
List in chronological order from oldest to most current your work history from the time you completed your medical training to the present. If more
.space is need attach sheet(s)
.Curriculum vitae (CV) are not sufficient as replacement for this section
Hospital Date (m/y)
QUEEN MARY HOSPITAL 10/2008-12/2010
Address City Country Postal Code
.1
IBAAN PHILIPPINES N/A
Department/ Specialty Staff Category Chairperson .Telephone No
EMERGENCY /SURGERY
STAFF NURSE Dr. Dioscoro Angelia
MEDICAL WARD /OPD
Hospital Date (m/y)
.2
SARAT ABEEDAH GENERAL HOSPITAL 11/2013 —12/2010
 Address City Country Postal Code
ABHA ASEER SAUDI N/A
Department/ Specialty Staff Category Chairperson .Telephone No
EMERGENCY
STAFF NURSE
DEPARTMENT N/A
Hospital Date (m/y)
KING SAUD HOSPITAL 05/2016 —06/2014
Address City Country Postal Code
.3
QASSIM UNAIZAH SAUDI
Department/ Specialty Staff Category Chairperson .Telephone No
EMERGENCY
STAFF NURSE
DEPARTMENT N/A
Hospital Date (m/y)

- From
Address City Country Postal Code
.4

Department/ Specialty Staff Category Chairperson .Telephone No

Hospital Date (m/y)

3
Address City Country Postal Code
.5

Department/ Specialty Staff Category Chairperson .Telephone No

Hospital Date (m/y)

Address City Country Postal Code

.6

Department/ Specialty Staff Category Chairperson .Telephone No

TIME INTERVALS
.Explain any time intervals not accounted for in application
.Please provide an explanation for any gaps greater 30 days in work history
Activity / Affiliation Date (m/y) Name/Address
N
).Ex: Military Service, Personal Leave, etc ( from to )For Verification Purposes(
.1 PERSONAL REASON 05/2016 01/2017
.2 ---- / -- ---- / --
.3 ---- / -- ---- / --
.4 ---- / -- ---- / --
REFERENCES
List three professional references, preferably from your specialty who not partners in your own group practice, not including relatives. NOTE:
.References must be from individuals who are directly familiar with your work, either clinical observation or close working relation
Name .1 Specialty Address
LARRAINE BAYHONAN EMERGENCY DEPARTMENT
City Country Postal Code
UNAIZAH QASSIM SAUDI N/A
 .Telephone No .Fax No Email
N/A N/A
Name .2 Specialty Address
VIRGINIA DE JESUS EMERGENCY DEPARTMENT
City Country Postal Code
UNAIZAH QASSIM SAUDI N/A
.Telephone No .Fax No Email
N/A N/A
Name .3 Specialty Address

City Country Postal Code

.Telephone No .Fax No Email

INSURANCE COVERAGE
.Please attach a copy of the current Certificate of Insurance
Name of Carrier .Policy No Dates of Coverage (m/y)
N/A N/A ---- / -- From ---- / -- to
Address of Carrier .Telephone No
N/A N/A

DISCLOSURE QUESTIONS
 Please check the appropriate response to the following question: YES NO
Question 1: /
Has your license to practice, in your profession, ever been denied, suspended, revoked, restricted, voluntarily surrendered while
under investigation, or have you ever been subject to a consent order, probation or any conditions or limitations by any authority
Hospital Privileges and Other Affiliations
Question 2: /
Have your clinical privileges or Medical Staff membership at any hospital or healthcare institution ever been denied, suspended,
revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-
completion of medical records when quality of care was not adversely affected) or have proceedings toward any of those ends
been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing boar
Question 3: /
Have you voluntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?
 Question 4: /
Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action,
by any managed care organizations?
 Question 5: /
Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship,
residency, fellowship, preceptor ship or other clinical education program? If you are currently in a training program, have you
been placed on probation, disciplined, formally reprimanded, suspended or asked to resign?
 Question 6: /
Have you ever, while under investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee
in any internship, residency, fellowship, preceptor ship, or other clinical education program?
  Question 7: /
Have any of your board certifications or eligibility ever been revoked?
 Question 8: /
Are you currently or have you ever been the subject of an investigation by any hospital, licensing authority, Ministry of health,
health authority or medical legal authority
Question 9: /
Have you ever received sanctions from or been the subject of investigation by any regulatory authority?
 Question 10: /
Have you ever been investigated, sanctioned by facility, or agency, or voluntarily terminated or resigned while under
investigation by a hospital or healthcare facility?
 Question 11: /
Have you had any malpractice actions within the past 10 years (pending, settled, arbitrated, mediated or litigated? If yes, please
check this box and complete and submit Attachment.
Question 12: /
Have you ever been convicted of, pled guilty that is reasonably related to your qualifications, competence, functions, or duties as
a medical professional
 Question 13: /
Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the
functions of your job with reasonable skill and safety?
Question 14: /
?Do you have any reason to believe that you would pose a risk to the safety or well-being of your patients

I understand and agree that, as part of the credentialing application process for participation and/or clinical privileges, I am required to provide
sufficient and accurate information for a proper evaluation of my current licensure, relevant training and/or experience, clinical competence, health
status, character, ethics, and any other criteria used by the Entity for determining initial and ongoing eligibility for Participation. Each Entity and its
representatives, employees, and agent(s) acknowledge that the information obtained relating to the application process will be held confidential to the
extent permitted by law.

I acknowledge that each Entity has its own criteria for acceptance, and I may be accepted or rejected by each independently. I further acknowledge
and understand that my cooperation in obtaining information and my consent to the release of information do not guarantee that any Entity will grant

5me clinical privileges or contract with me as a provider of services. I understand that my application for Participation with the Entity is not an
application for employment with the Entity and that acceptance of my application by the Entity will not result in my employment by the Entity.

For Hospital credentialing. I consent to appear for an interview with the credentials committee, medical staff executive committee, or other
representatives of the medical staff, hospital administration or the governing board, if required or requested. As a medical staff member, I pledge to
provide continuous care for my patients. I have been informed of existing hospital bylaws, rules and regulations, and policies regarding the
application process, and I agree that as a medical staff member, I will be bound by them.

Authorization of Investigation Concerning Application for Participation. I authorize the following individuals including, without limitation
Authorization of Third-Party Sources to Release Information Concerning Application for Participation. I authorize any third party, including,
but not limited to, individuals, agencies and medical groups responsible for credentials verification

I certify that all information provided by me in my application is true, correct, and complete to the best of my knowledge and belief, and that I will
notify the hospital within 10 days of any material changes to the information I have provided in my application or authorized to be released pursuant
to the credentialing process. I understand that corrections to the application are permitted and must be submitted on-line or in writing, and must be
dated and signed by me). I understand and agree that any material misstatement or omission in the application may constitute grounds for withdrawal
of the application from consideration; denial or revocation of Participation; and/or immediate suspension or termination of Participation.

I further acknowledge that I have read and understand the foregoing Authorization, Attestation and Release. I understand and agree that a facsimile or
photocopy of this Authorization, Attestation and Release shall be as effective as the original

______________________________
SIGNATURE

 MICHELLE MAGSINO
______________________________
NAME (PLEASE PRINT OR TYPE)

_____________06/03/17________________
Date