Draft Attachment J.5-Clinical West Credential File Format.pdf
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- Solicitation number
- PSCFOH-ClinicalWest-PSC347298
About this file
This document is a credential file format template that specifies required documentation for credentialing medical professionals at a facility of health (FOH). The template establishes standardized credential requirements organized into six sections for four provider types: Physicians, Nurse Practitioners (NPs), Physician Assistants (PAs), and Nurse Practitioners (NPs).
Section 1 requires attestation of completion by the vendor, NPDB authorization, FOH privileges documentation with signatures, and a FOH privileging letter. Section 2 mandates application for medical staff appointment with privileges request, I-9 verification, and malpractice or errors and omissions insurance documentation with claims history. Section 3 addresses professional qualifications and includes primary source verified credentials such as state licenses, medical education (medical school, internship, residency, fellowship, preceptorship), board certifications, ECFMG certification if applicable, security clearance and background check within three months of initial application, Office of Inspector General sanction report, and BLS certification from accredited providers with hands-on components. Section 4 requires performance evaluations for the past three years. Section 5 includes job-specific position description, orientation checklists and documentation, current CV or résumé, continuing professional education, three completed peer reference forms, letters of appreciation or commendation, and personnel action documentation. Section 6 mandates annual clinical provider documentation including flu vaccine, tuberculosis testing with results or annual questionnaire at renewal, and hepatitis B vaccine, titer, or waiver documentation. Requirements vary slightly by provider type, with physicians requiring additional educational verification and NPs/PAs requiring specific certification documentation relevant to their respective roles.
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Draft 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)
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