Request for Membership: DeBakey Heart & Vascular Center

Please complete the fields below to be considered for membership in the Houston Methodist DeBakey Heart & Vascular Center (HMDHVC)

• Membership applications will be considered on a rolling basis
• Criteria must be met within 12 months of initial application. Following the inaugural year criteria requirements will be presented to the leadership committee for review every 12 months.
• Applicants must meet all requirements
• Please note, members must reapply every three years
• For more information and/or questions, please email debakeymembership@houstonmethodist.org

First name * Middle initial Last name * Address * Suite City * State * AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Postal code * Phone * Email address *

Membership Commitment

I promise to:

Accept and continue my appointment to the medical staff, with privileges to practice cardiovascular (CV) medicine at one or more Houston Methodist facility * Yes No Demonstrate support of the mission, vision, goals and objectives of the HMDHVC * Yes No

Commitment to DeBakey Heart and Vascular Center Services

Participate in at least 50% of Cardiology or Cardiovascular Surgery Service Line meetings at the Houston Methodist hospital where the majority of my practice occurs * Yes No Participate in hospital-based quality standards performance measurement as well as performance improvement processes * Yes No Participate in quality assurance reviews, national guideline adherence reviews, and the NCDR/STS registry (where applicable) * Yes No Adhere to the Houston Methodist Accountable Care Organization’s CV protocols, established for patients enrolled in this program, by providing clinical information on patients to networks on a timely basis * Yes No Adhere to protocols established as part of any other clinically integrated network sponsored by Houston Methodist * Yes No Participate in community and/or patient outreach activities sponsored by Houston Methodist, as requested * Yes No

Commitment to Education and Research

Collaborate with DeBakey Heart & Vascular Center research programs to extend available clinical trial information to eligible patients in my practice * Yes No

Commitment to Excellence

Attend and/or participate in a local, regional or national CV medical conference bi-annually * Yes No Adhere to national treatment guidelines and best practices * Yes No