Healthcare Provider Privileges Packet

HEALTHCARE PROVIDER PRIVILEGES PACKET

Facility Name:   Department:   Application Date:

PROVIDER IDENTIFICATION

Date of Birth:   Gender:

Phone:   Email:   NPI Number:

LICENSURE, BOARD CERTIFICATION, AND CREDENTIALS

Issue Date:   Expiration Date:   License Status:

EDUCATION, TRAINING, AND PROFESSIONAL HISTORY

REQUESTED PRIVILEGES AND PRACTICE SCOPE

Privileges Requested (medical/surgical procedures, consultative privileges, inpatient/outpatient):

Temporary Privileges Requested:   If yes, requested start date:

PROFESSIONAL LIABILITY / INSURANCE

Policy Number:   Limits:   Expiration:

Policy Type: Occurrence    Claims-made

Any claims or suits in the last ten years? Yes No

DISCIPLINARY, CRIMINAL, AND PROFESSIONAL ACTIONS

Have you ever had any license revoked, suspended, limited, or subject to probation? Yes No

Have you ever been convicted of a crime (felony or misdemeanor) or are there any pending criminal charges against you? Yes No

REFERENCES

Provide three professional references who can attest to clinical competence and ethical conduct.

AUTHORIZATIONS, CERTIFICATIONS, AND ATTESTATIONS

By signing below, I certify under penalty of perjury that the information provided in this application and any attachments is true, correct, and complete to the best of my knowledge. I authorize the facility and its agents to obtain and verify information regarding my education, training, licensure, current competence, professional liability history, criminal record, and any other information pertinent to the evaluation of this application from any source, including but not limited to hospitals, licensing boards, educational institutions, professional references, and insurers.

I understand that any misrepresentation, omission, or falsification of information is grounds for denial, revocation, or limitation of privileges and may be reported to appropriate licensing and regulatory bodies. I agree to comply with the facility's bylaws, rules, and policies, and to participate in quality assurance and peer review activities as required.

I consent to the release of peer review and other privileged quality improvement information to authorized entities in accordance with applicable law and understand that privilege and confidentiality protections may apply to certain information.

ADDITIONAL DOCUMENTS ATTACHED

Please indicate documents attached to this packet (check all that apply):

Curriculum Vitae    Board Certificates    Licenses    Malpractice Declarations

PRIVACY & HIPAA ACKNOWLEDGMENT

I acknowledge that I have read and understand the facility's privacy and HIPAA policies as provided to me and agree to comply with patient privacy and security obligations in connection with the exercise of any granted privileges. I authorize the release of my protected health information and other records to authorized reviewers for the purpose of credentialing and peer review, understanding that such disclosures are for credentialing and quality improvement and are subject to applicable protections.

ATTESTATION OF UNDERSTANDING

I understand that the granting of privileges is not a contract for employment and does not guarantee employment or any specific patient volume. I understand that privileges may be proctored, limited, suspended, or revoked in accordance with facility bylaws, rules, or applicable law. I agree to notify the facility within 30 days of any change in the information provided in this packet.

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