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