Attachment_2_Credentialing.docx
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- Solicitation number
- W91YTZ-16-R-0058
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Department of the Army Medical Command
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Attachment 2 Credentialing
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| File | Type | Posted |
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| W91YTZ-16-R-0058-0002.pdf | ||
| A01_Sol_Amend_2_Attach_9_Questions_generated_after_Sol_Amendment_1.docx | DOCX document | |
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ATTACHMENT 2 - Checklist for Initial and Renewal of Credentials
| Name: | Expiration of Privileges: | |||||
| Dept/SVC: | Specialty: | |||||
| Appointment: | Initial | Active | Temporary | Affiliate | ||
| Privileges: | Regular | Temporary | Supervised |
Provider Review: Clinical Supervisor:
DA 4691-1 Renewal Application DA 5440A Approval Signature
DA 5440A Approval of Clinical Privileges DA 5440- Approval of Delineation
DA 5440- Delineation(s) Request for Clinical Priv/Med Staff Appt
Request for Clinical Priv/Med Staff Appointment Completed DA5374 (Performance Assessment)
Provider Information Sheet Completed 5441- (Evaluation)
2 Peer References
DA 5754 Malpractice/Health
CME Record
Current copy of BLS/ACLS/PALS/NRP/ATLS
ICTB (Transfer Brief if required) expiration.
Release of Information
Memorandum on Physician Licensure (if app.)
Copy of Current Licensure
NPI Number DEA Number
| BLS | ACLS | PALS | NRP | ATLS | |||
| Licensure/State: | Active/Good Standing | Exp Date: | Verified On: |
Board Cert/Spec Cert: Exp Date: Verified On:
NPDB Query: YES/NO Adverse Information on Databank Report Run on:
CME/CEU earned since last credentialed:
| Professional Degree | Year | Verified On: | ||
| Internship | Year | Verified On: | ||
| Residency | Year | Verified On: | ||
| Fellowship | Year | Verified On: |
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