Attachment J.5 - Credential File Format.docx

Attachment J.5 – Credential File Format

Physicians:

Section 1 Attestation of Completion (Completed by Vendor) NPDB Authorization Form FOH Privileges, Recommendation and Dispensation with signatures FOH Privileging Letter

Section 2 Application for Appointment of Medical Staff with Privileges Request Form Proof of I-9 Completion/Identity Verification Certificate of Malpractice Insurance or Errors and Omissions Insurance Insurance Claims History

Section 3 Professional License – State or U.S. Territories/Commonwealth (current and past, active and inactive), primary source verified Medical School: primary source verified Educational Commission for Foreign Medical Graduates Certification (ECFMG), if applicable Internship: primary source verified Residency: primary source verified Fellowship: primary source verified, if applicable Preceptorship: primary source verified, if applicable Relevant Specialty: primary source verified, if applicable Board Certifications: primary source verified Security Clearance/Background Check performed within 3 months of initial application Office of Inspector General Sanction Report Basic Life Support (BLS) Certification from American Heart Association, Red Cross or American Health and Safety Institute accredited course (must contain hands-on component)

Section 4 Performance Evaluation (for the past 3 years)

Section 5 Job Specific Position Description, signed Initial Orientation Checklist Site Specific Orientation Documentation (signed) Curriculum Vitae or Résumé, current Continuing Professional Education (all other) FOH Peer Reference Form(s) (3 completed forms) Letters of Appreciation/Commendation and Awards Documentation of Personnel Actions

Section 6 Annual Tuberculosis (TB) Test Documentation (with reported results) and/or Annual Questionnaire at renewal (for clinical providers) Hepatitis B Documentation (vaccine, titer, or waiver) (for clinical providers) Flu Vaccine documentation, annual (for clinical providers)

Nurse Practitioners (NPs):

Section 1 Attestation of Completion (Completed by Vendor) NPDB Authorization Form FOH Privileges, Recommendation and Dispensation with signatures FOH Privileging Letter

Section 2 Application for Appointment of Medical Staff with Privileges Request Form Proof of I-9 Completion/Identity Verification Certificate of Malpractice Insurance or Errors and Omissions Insurance Insurance Claims History

Section 3 American Academy of Nurse Practitioners’ Current Certification: primary source verified Professional Licenses RN and NP (current and past, active and inactive): primary source verified Nurse Practitioner Program completion: primary source verified Internship: primary source verified, if applicable Security Clearance/Background Check performed within 3 months of initial application Office of Inspector General Sanction Report Basic Life Support (BLS) Certification from American Heart Association, Red Cross or National Safety Council accredited course (must contain hands-on component)

Section 4 Performance Evaluation (for the past 3 years)

Section 5 Curriculum Vitae or Résumé, current Initial Orientation Checklist Site Specific Orientation Documentation, signed Job Specific Position Description, signed Continuing Professional Education (all other) FOH Peer Reference Form(s) (3 completed forms) Letters of Appreciation/Commendation and Awards Documentation of Personnel Actions

Section 6 Flu Vaccine documentation, annual (for clinical providers) Annual Tuberculosis (TB) Test Documentation (with reported results) and/or Annual Questionnaire at renewal (for clinical providers) Hepatitis B Documentation (vaccine, titer, or waiver) (for clinical providers)

Physician Assistants (PAs):

Section 1 Attestation of Completion (Completed by Vendor) NPDB Authorization Form FOH Privileges, Recommendation and Dispensation with signatures FOH Privileging Letter

Section 2 Application for Appointment of Medical Staff with Privileges Request Form Proof of I-9 Completion/Identity Verification Certificate of Malpractice Insurance or Errors and Omissions Insurance Insurance Claims History

Section 3 State Physician Assistant License/Certification (active and inactive): primary source verified Professional Certification (current and past, active and inactive): primary source verified Accredited Physician Assistant Program: primary source verified Internship: primary source verified Security Clearance/Background Check performed within 3 months of initial application Office of Inspector General Sanction Report Basic Life Support (BLS) Certification from American Heart Association, Red Cross, or National Safety Council accredited course (must contain hands-on component)

Section 4 Performance Evaluation (for the past 3 years)

Section 5 Curriculum Vitae or Résumé, current Job Specific Position Description, signed Initial Orientation Checklist Site Specific Orientation Documentation, signed Continuing Professional Education (all other) Peer Reference Form(s) (3 completed forms) Letters of Appreciation/Commendation and Awards Documentation of Personnel Actions

Section 6 Flu vaccine documentation, annual (for clinical providers) Annual Tuberculosis (TB) Test Documentation (with reported results) and/or Annual Questionnaire at renewal (for clinical providers) Hepatitis B Documentation (vaccine, titer, or waiver) (for clinical providers)