2023 CA-MED IRT Online Submission Forms
Steps are listed below to prepare for the arrival of IRT Staff Members
- NCOIC or COIC are responsible for completing these tasks and communicating/coordinating these tasks with KMC IRT Coordination Team. It is very important to be prepared prior to IRT Mission Date.
Please complete all forms located below to submit online:
- Forms to be completed and submitted by May 9, 2023 Deadline:
- ITAC Form
- For Providers, you must complete and submit the KMC Online Privileging and Credentialing Packet: (forms in packet are listed below)
- Applicant Release Form
- Medical Privileges Request Form
- Behavioral Health, Dental, or Medical Credentialing Application
- General Consent for Treatment and Third-Party Billing
- Health Statement Form
- Influenza Declination Form
- Hepatitis B Declination Form
- TB Adult Tuberculosis Risk Assessment Form
- Please complete KMC HR Employee Packet: (forms in packet are listed below)
- IRT Staff Member Contact Information Form
- KMC Employment Application
- KMC Confidentiality Form
- KMC Emergency Contact Form
- KMC Employee Statement: Abuse Form
- KMC Mission & Vision Form
- KMC Photo Release Form
- Please review KMC Personnel Policies located here
- KMC PP Manual Receipt Form
- KMC Background Form
- Please review KMC Employee Handbook located here
- FIT Testing and Verification must be received no later than July 1, 2023
All Forms are located below under Supporting Documents
Day of Arrival: IRT Staff Member will be assigned Door Codes, receive a visitor's badge, complete ISSA Training, and complete COVID-19 Testing
To review an introductory video to our EHR (RPMS), please click here
KMC IRT Coordination Team Contact Information: If you have any questions, please contact Jene Moore at Extension 0272