Credentials Checklist for Incoming Contracted Providers.doc
DOC document 43 KB Posted
- Attached to
- Pain Management Anesthesiologist Solicitation
- Solicitation number
- FA5587-12-R-0026
About this file
Credentialing Paperwork 1 of 4 these documents need to be completed and submitted as part of the complete proposal.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| FA5587-12-R-0026-Amendment3.pdf | ||
| FA5587-12-R-0026-Amendment 2.pdf | ||
| FA5587-12-R-0026-Amendment 1.pdf | ||
| AF_Form_1540_final-2004 1 .rtf | RTF text file | |
| 1562.docx | DOCX document | |
| AF Form 22 Revised 2010.doc | DOC document | |
| FA5587-12-R-0026-Pain Management Anesthesiologist.pdf | ||
| SYNOPSIS.docx | DOCX document |
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Text version
Credentials Checklist for Incoming Contracted Providers To the 48th Medical Group
| 1. |
| Form to be completed by provider: |
a. AF Form 1540, APPLICATION FOR CLINICAL PRIVILEGES/MEDICAL STAFF APPOINTMENT
| 2. |
| Form to be completed by provider’s supervisor and forwarded directly to 48 MDG or from the contractor |
a. AF Form 22, CLINICAL PRIVILEGES EVALUATION SUMMARY
| 3. |
| Form to be completed by two references and forwarded directly to 48 MDG or from the contractor |
a. AF Form 1562, CREDENTIALS EVALUATION OF HEALTHCARE PRACTICIANERS (reference list should match the names on the AF 1562)
| 4. |
| Items to be sent by provider /Contractor |
a. AF Form 1540, AF Form 22, AF Form1562
b. Copies of current evaluations
c. Copies of current privilege list and/or job description
d. Copies of life support cards (BLS, ACLS, ATLS, …)
e. Copies of diplomas
f. Copies of post-graduate training
g. Copies of board certifications
h. Copies of continuing education certificates
i. Explanation of all gaps of 30 days or more from the date of the qualifying degree
j. DEA number registration information
| 5. |
| Mailing addresses: |
By USPS: By FedEx/DHL:
48 MDG/SGHC RAF Lakenheath
Unit 5210 Box 230 48 MDG/SGHC, Attn: Estella Decoster
APO AE 09461-0230 Bldg 922, Rm 220
Brandon, Suffolk IP28 9PN
Great Britain
PROVIDER: _______________________________
PROJECTED ARRIVAL DATE: ________________
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