Exhibit E - Credentialing Checklist.pdf
PDF 685 KB Posted
- Solicitation number
- HT001524R0030
- Issued by
-
Defense Health Agency
About this file
This document is a checklist for credentialing and privileging required documents from contract vendors providing services to the Augusta Military Medical Center Ambulatory Care Center. It lists all primary source verifications that must be stamped with the vendor's verification stamp including licenses, education, training, board certification, employment history, NPDB report, CMEs/CEUs, curriculum vitae, contingency training, AMA and AOA profiles, and justification for any gaps in employment. It also requires proof of employment, two peer references within the last 12-24 months, verification of photo ID, and indicates all other forms are obsolete and the current form is dated July 1, 2020. The related federal contract opportunity is a solicitation for the AT Augusta Military Medical Center Ambulatory Care Center with number HT001524R0030 from the Defense Health Agency.
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All Primary Source Verifications must be stamped with Vendor’s Verification Stamp with Date and Signature
CHECKLIST FOR CONTRACT PROVIDERS
CREDENTIALING & PRIVILEGING
(REQUIRED DOCUMENTS from CONTRACT VENDOR)
PRIME SOURCE VERIFICATION OF:
All ACTIVE and INACTIVE licenses
Education (Qualifying Degree such as MD/DO/MSN/BSN)
Training (Internship, Residency, Fellowship)
Board Certification/National Certification/Specialty Certification
Employment for the past 10 years (or from the point of completing advanced training for recent graduates with less than 10 years of experience)
NPDB report
CME/CEU
Curriculum Vitae/Resume
Contingency Training (BLS, ACLS, NRP, etc... *Note: BLS must be obtained by the American
Red Cross or the American Heart Association)
AMA profile (can only be used for verification of education and training but NOT board certification.)
AOA profile (can only be used for verification of education and training but NOT board certification.)
Review for Gaps in Employment: All gaps in employment greater than 30 days must be justified and/or explained. All professional work time from the point of graduating from qualified training must be included on the Curriculum Vitae.
Proof of Employment: Memo providing the name of employee, position/specialty of employee, contract number, type of contract (NPSC or PSC) and employee start/end date.
Peer References. Two peer references are required. Peers should share the same specialty as the candidate applying for privileges. The individual must be able to attest to the candidate's clinical skills within the last 12‐24 months. Please provide the individual's full name, specialty, email address and phone number. FBCH Credentials Office will contact the peer reference on the candidate's behalf.
______Verification of Identification/Photo ID: Copy of a current valid picture identification issued by a federal or state agency, such as driver’s license or passport.
FORM C1 dated: 20200701: All other forms are obsolete
ATAMMC PWS Exhibit E - Credentialing Checklist
File details come from the government source that posted it. Updated .