Healthcare Temporary Privilege Request

HEALTHCARE TEMPORARY PRIVILEGE REQUEST

This form is a formal request for temporary clinical privileges at the facility named below. Temporary privileges, if granted, are limited, time‑bound, and subject to verification of credentials and compliance with the medical staff bylaws, rules, and applicable hospital policies. Complete all sections and attach required supporting documentation.

Requesting Facility

Provider Information

Male    Female    Other

Licensure and Certification

Board Certified: If checked, list board and certification date:

Proposed Temporary Privileges

Locum tenens    Emergency coverage    Disaster response    Pending full credentialing    Visiting consultant    Other

Supervision, Proctoring, and Coverage

Proctor required for initial cases: If yes, proctor name:

Insurance / Malpractice

Policy Expiration:

Supporting Documentation (attach copies)

Current Curriculum Vitae    Current State License    Malpractice Declarations   

DEA Certificate    Board Certification    Professional References

Background Check / U.S. Primary Source Verification    Other:

Conditions, Limitations, and Authority

1. Temporary privileges, if granted, shall be limited to the specific services and time period approved by the Medical Staff or its designee. Temporary privileges do not confer membership rights and are subject to the hospital medical staff bylaws, policies, and applicable law.

2. Granting of temporary privileges is conditioned upon verification of primary source information where possible, proof of current malpractice insurance with required limits, current licensure, and any other documentation the facility deems necessary. The facility may revoke or restrict temporary privileges at any time for cause or upon discovery of discrepant or adverse information.

3. The practitioner agrees to comply with all applicable hospital rules, clinical protocols, reporting requirements, and quality review processes. The practitioner shall accept supervision or proctoring as required and participate in peer review concerning care provided under temporary privileges.

4. Temporary privileges will automatically expire on the date specified above, or earlier if revoked by the hospital. Extensions may be granted only upon documented justification and prior review consistent with the medical staff procedures.

5. The practitioner authorizes inquiry and release of information from past and present employers, professional references, licensing boards, malpractice carriers, and other sources to evaluate this request. The practitioner certifies that information provided on this form is true, complete, and accurate to the best of their knowledge and understands that falsification or omission may be grounds for denial, revocation, or disciplinary action.

Requesting Department Representative (Attestation by Chair or Designee)

Credentialing Office Use Only

Approved    Denied    Pending - documents required

Applicant Attestation and Authorization

By signing below I certify that the information provided on this form and in the attached documents is true and complete. I authorize the facility, its agents, and medical staff peer review bodies to obtain and verify information from all relevant sources, including licensing authorities, malpractice carriers, employers, educational institutions, and references. I understand that temporary privileges may be revoked or limited and that I remain subject to all applicable bylaws, policies, and reporting requirements. I further authorize release of my credentialing and practice information to third parties as required for quality assessment and legal compliance.

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