Request for Membership: Lynda K. and David M. Underwood Center for Digestive Health

Please complete this form to be considered for membership in the Houston Methodist Underwood Center for Digestive Health.

• Underwood Center Mission and Vision.
  • Mission: The Underwood Center will bring together physicians and other healthcare professionals to provide comprehensive and integrated care for patients with digestive disorders.
  • Vision: The Underwood Center will be the premier regional and nationally recognized center providing comprehensive, multidisciplinary care, based on best evidence and in a context of research and education with access to leading-edge diagnostics, therapeutics and technology, while provided in a caring and supportive environment.
• Membership applications will be considered on a quarterly basis.
• Applicants must meet all requirements.
• Criteria must be met within six (6) months of initial application and the granting of associate membership. Full membership will be at the discretion of the Executive Oversight Committee and based on the fulfillment of membership requirements.
• Please note, members must reapply every three years.
• For more information and/or questions, please email: underwoodcenter@houstonmethodist.org

Benefits of Membership include:

• Listed as a Member, Houston Methodist Underwood Center for Digestive Health in the Houston Methodist Physician Referral database.
• Featured as a Member, Houston Methodist Underwood Center for Digestive Health on the physician's web profile on the Houston Methodist website.
• Listed as a member on the Houston Methodist Underwood Center for Digestive Health web page.
• Listed as a member in the Houston Methodist Underwood Center for Digestive Health biennial report.
• Invited to participate in Houston Methodist Underwood Center for Digestive Health focused marketing activities.
• Members have access to new technology and competency enhancement.
• Eligibility to hold a leadership position at a Houston Methodist facility or an affiliated academic institution including but not limited to Hospital department deputy leadership, membership in the Underwood Center’s Executive Oversight Committee or Leadership Council, hospital based digestive disease program leadership role, leadership or membership of a digestive disease program committee, subcommittee or workgroup.

 

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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 * What is your primary Houston Methodist location? * Houston Methodist Hospital (Medical Center) Houston Methodist Baytown Hospital Houston Methodist Clear Lake Hospital Houston Methodist Sugar Land Hospital Houston Methodist The Woodlands Hospital Houston Methodist West Hospital Houston Methodist Willowbrook Hospital

Membership Requirements

I promise to:

Accept my appointment to the medical staff, with privileges to practice digestive health medicine at any Houston Methodist facility. * Yes No Demonstrate support of the mission, vision, goals and objectives of the Underwood Center. * Yes No Participate in hospital-based quality standards performance measurement as well as performance improvement processes. * Yes No

Membership Questions

Within the last 12 months

IMPORTANT: Please do not use special characters in the form fields below, for example: ( ), [ ], { }, < >

If copying from a document, such as your CV, please paste as plain text.

List any leadership position(s) held at Houston Methodist or an affiliated academic institution. List any local, state, national, or international gastroenterology or GI surgical committee(s) or council(s) in which you serve as a leader or member. Do you participate in institutional gastrointestinal or GI surgery conferences (e.g., grand rounds, multi-disciplinary conference, GI tumor boards, meetings), if so, please specify. List, if applicable, a community and/or patient outreach activity sponsored by the Underwood Center that you participated in or would be interested in participating in. List any citations to Underwood Center in authorship affiliation for the past year (not applicable to initial application). List gastroenterology or GI surgery related clinical or research-based studies in which you are an investigator or collaborator. List regional or national gastroenterology or GI surgery conference(s) you attended and/or participated in. Would you be interested in participating, as an investigator, in clinical trials or registries? Yes No

Commitment to Gastroenterology & GI Surgery Services

Participate in at least 50% of gastroenterology, general/colorectal, or other related service line meetings at the Houston Methodist hospital where the majority of my practice occurs. * Yes No Participate in quality assurance reviews, national guideline adherence reviews, and the GIQuIC/ACS registry (where applicable) * Yes No Participate in community and/or patient outreach activities sponsored by Houston Methodist, as requested. * Yes No

Commitment to Research

Collaborate with Underwood 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 digestive disease medical conference bi-annually. * Yes No Adhere to national treatment guidelines and best practices. * Yes No

Agreement for Membership

I understand and agree that my membership in the Underwood Center for Digestive Health is dependent upon my continued compliance with the “Underwood Physician Membership and Criteria Standards”. If Houston Methodist determines that I no longer meet these criteria, then my membership in the Underwood Center will immediately and automatically cease. My loss of membership in the Underwood Center is separate from my medical staff membership and does not entitle me to any due process or fair hearing under the Houston Methodist medical staff bylaws.

I understand and agree * Yes No

Use of Houston Methodist and Underwood Center Name and Marks

I agree that the names “Houston Methodist Hospital” and “The Underwood Center for Digestive Health” are service marks of Houston Methodist, and that any use I am permitted to make of those marks or any other marks of Houston Methodist based upon my membership in the Underwood Center will cease upon cessation of my membership. I understand that any unpermitted use of these marks will cause harm to Houston Methodist that may not be possible to determine in monetary damages, so Houston Methodist may seek an injunction to curtail any such use without posting a bond.

I agree * Yes No

Disclaimer

To the best of my knowledge, the information I have provided in this membership application is accurate. I authorize the release of information relevant for my membership in the Underwood Center. I agree to hold the Underwood Center, its members, officers and representatives free from any damage or complaint by reason of any action they may take in connection with this application.

I agree to this application's accuracy * Yes No I have read the “Physician Membership Criteria and Standards” and if approved for membership, I agree to subscribe to and abide by the guidelines. * Yes No Full name/Signature *