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Policy: Credentialing and PrivilegingDate: December 6, 2011CREDENTIALING: BEFORE HIREAll provider applicants will submit the necessary documents for credentialing. Original Source Verification will be required of all essential documents. Every effort will be made to have all paperwork in order at every step in the process.The following documents will be required and incorporated into the credentialing process: Curriculum Vitae Application EEOC Professional References Release of Information Credentialing Statement & Attestation as to Correctness and Completeness of the Application Professional license and certification numbers Pre-Screening and Interview NotesCriminal/Education Background FormGoogle Search Physician Profile -AMA, ECFMG (For MDs/DOs/PAs or NCCPA -Not for NPs) American Nurses Credentialing Center (ANCC) or American Academy of Nurse Practitioners (AANP) for NPsNCCPA –Physician Assistant Verification American Dental Association (For Dentists Only) License to Practice or NURSYS Nurse Practitioners Out-of-State –For NPs there are two (RN and NP) Minnesota Controlled Substance DEA Registration Sanctions or Limitations on Licensure or Previous Sanctions by Medicare/Medicaid National Practitioner Data Bank Healthcare Integrity & Protection Data Bank (Malpractice/Loss History) Physical capacity and/or Functional capacity assessment, as determined by job descriptionCREDENTIALING: AFTER OFFER/HIREAn Employment Agreement will be reviewed with and signed by the provider applicant prior to commencing employment and clinical work.The following documents will be assembled, organized and again verified: Collaborative Agreement (Non-Physician Providers) as Appropriate Verification of Picture Identification -Must obtain copy of state issued picture ID plus copy of one of the following federal government issued identification –social security card, passport, birth certificate, certificate of U.S. citizenship, certificate of naturalization, permanent resident card, unexpired temporary resident card. Copy of Original Diplomas Copy of Original Specialty License Copy of Original Verified Training (i.e. residency or NP program)Documentation of Continuing Professional Education (as applicable) Life Support Training (BLS, ACLS, ATLS, CPR, PALS, etc. as applicable) Copy of Original DEA Document Copy of Original Controlled Substance License Copy of Residency Certificate Copy of Medical Education Certificate Copy of CPR and other position related documentationImmunization/PPD/TB status Pre-Employment Health Fitness assessment Copy of Car Insurance Company Verified Current Competence (from last Medical/Program Director)PRIVILEGINGAll providers providing clinical care at Cedar Riverside People’s Center will have privileges to practice and provide clinic care granted by the Board of Directors. Recommendations for granting these privileges will be made by the Chief Medical Officer based on his/her review, and input from an ad hoc Professional Review Committee that might be established, composed of other appropriate clinicians on the medical staff.Provider applicants for privileges should submit their credentials and allow enough time for the privileging process to be accomplished before starting their clinical practice at their clinical locations.All providers at Cedar Riverside People’s Center will apply for specific procedures regarding their clinic practice in the clinic(see attached)Documents needed to grant privileges will include, but not be limited to, the following documents: State medical license Specialty board certification Curriculum vitae with past clinical experience, both outpatient and inpatient Other documentation of formal training or certification Any documentation of prior adverse findings from a specialty board or other regulatory board regarding the provider’s clinical practiceIn general, the scope of practice and procedures that are a part of standard specialty training within the particular specialty training shall be granted to the provider. A specific checklist of scope of practice and procedures shall be completed as part of the privileging process (see attached) Copies of all relevant documents shall be kept in the provider’s personnel file Additional training that would permit additional clinical privileges shall be presented to the Chief Medical Officer as well as any credentials committee in effect at the time, for review in order to grant additional clinical privileges.Every effort will be made to make sure the new provider applicant returns all paperwork to the credentialing department and Chief Medical Officer, so the credentialing can copy all information and issue check if necessary.The credentialing department will review all paperwork for accuracy and completeness.There will be ongoing follow up with the provider regularlyATTACHMENT:PRIVILEGED AND CONFIDENTIALProceedings and Records of the Professional Review CommitteeCedar Riverside People’s CenterREQUEST FOR PRIVILEGESLICENSED OR CERTIFIED HEALTH PROFESSIONALSPosition Title: 960120762000I hereby request the attached privileges/scope of practice/competencies for which I am trained and experienced to perform, as listed on the attached forms. I understand that it is my responsibility to demonstrate my competence to perform the listed privileges. I understand that the privileges requested may differ from those finally approved. I further understand that the completion of this form at this time does not preclude me from requesting additional privileges in the future.37033207683500-685807683500Signature of Applicant Date-6858010096500Print NameAttachment (List of privileges, scope of practice or competencies)Note: The requested privileges must be reasonably comprehensive (i.e., not just specialty designation), must be based on documented education, training and/or experience, and must be specific to the job description you are applying for at the Center. Provide information on any special training you may have had that qualifies you for additional services or functions.Please attach a delineation of privileges, scope of practice, competencies or detailed job description. If you are requesting privileges or functions in addition to those listed on the job description, please indicate accordingly on the attachment.PRIVILEGED AND CONFIDENTIALProceedings and Records of the Professional Review CommitteeCedar Riverside People’s CenterAPPLICATION FOR CLINICAL PRIVILEGESGeneralGranting, reviewing, and changing of clinical privileges for the staff of the Cedar Riverside People’s Center will be accordance with Health Center policy. Assignments of such clinical privileges are based upon education, clinical training, experience, demonstrated current competence, documented results of patient care, and other quality review and monitoring deemed appropriate. The principle of “documented competency” will prevail. Primary care medicine is a dynamic and comprehensive field. Adult medicine, pediatric care, prenatal care, outpatient surgical care, and mental health care are integral components of Health Center continuity of care. As a result, privileges in these areas are identified to pertain to primary care, specialties of pediatrics, internal medicine, family practice, general practice, midwifery and obstetrics/gynecology.The privileges for the Center will be granted in the following three classes:Level One(General)This class includes privileges for uncomplicated, basic procedures and clinical application of cognitive skills. Physicians applying for privileges in this class will be graduates of approved medical/osteopathic schools who are properly licensed and demonstrate skills in appropriate general medicine practice.Level Two(Residency/Board Certification)Privileges in this class include Level One privileges as well as privileges for those procedures and cognitive skills involving more serious medical problems which are normally taught in residency programs. This will include procedures and clinical application of cognitive skills appropriate to the care in perinatal, surgical, psychiatric, and critical care units. Physicians requesting privileges in this class will have to meet criteria in Level One and have either completed training in a residency program and/or will be Board Certified, or will have documentation experience, demonstrated abilities and current competence in primary care medicine.Level Three(Advanced Procedures)Privileges in this category include privileges in Level One and Two. Additional privileges may be granted to physicians who have acquired added experience and/or training, and who have special skills and knowledge in specified areas of medicine. As appropriate, the Medical Director will review these additional privileges.********It should be noted that, even though a physician is assigned to one of the three classes, he or she might also elect to apply for individual privileges that may be considered to be a higher level.PRIVILEGED AND CONFIDENTIALProceedings and Records of the Professional Review CommitteePRIVILEGE REQUEST FORM118872011620500Print Name: 118872013779500Hire Date: 118872015938500Primary Location: 416052010096500118872010096500Board Certified: Date: 4160520882650011887208826500Subspecialty: Date:Board Eligible:Projected Certification Date:17602205080001188720-57150000Write the number of the level and clinical site that applies for each privilegePrivilege Level:3589020190530031188720190520024572019051001 (General) (Residency/Board Certification) (Advanced Procedures) ProceduresRequestedLevelSiteMedical Director ApprovalSpecial Conditions/CommentGeneral PrivilegesManagement of Routine Adolescent CareManagement of Routine Adult CareManagement of Routine Geriatric CareSupervision of StudentsProceduresRequestedLevelSiteMedical Director ApprovalSpecial Conditions/CommentBiopsy, skinCardiopulmonary resuscitation (BLS)Excision, benign lesion, skinForeign body removal, eyeAbscess I & DIngrown toenail excisionLacerations, infectedParanychia, I & DSuturing of simple lacerationPrivileges in Anesthesia CareUse of local anesthetics for wound repairUse of topical anestheticsPrivileges in Internal MedicineDebridement, skin subcutaneous, tissueDressing/Debridement, burnIncision and removal of foreign bodyLaceration, simplePrivileges in Internal MedicineIndependent Care: Basic Life SupportBasic Diagnosis & ManagementFull care of uncomplicated casesEKG interpretationNeedle aspiration of subcutaneous lesionPRIVILEGED AND CONFIDENTIALProceedings and Records of theProfessional Review CommitteeProceduresRequestedLevelSiteMedical Director ApprovalSpecial Conditions/CommentPFT (Pulmonary Function Test) interpretationSuperficialNerve block)Privileges in Gynecological CareI & D Bartholin CystCervical BiopsyColoposcopy/Cervical CryotherapyEndometrial BiopsyIUD insertion and removal: ParagardIUD insertion and removal:MirenaPrivileges in Orthopedic CareInitial evaluation of orthopedic problemsTreatment of acute back and neck painTreatment of contusions, simple lacerations, sprainsTreatment of bursitis, tendonitis, tennis elbow, etc.Casting procedures for closed fractures requiring no reductionJoint aspirationsProcedures involving destruction of nail bedsTreatment of corns, calluses and bunionsFoot careTreatment of closed dislocations ProceduresRequestedLevelSiteMedical Director ApprovalSpecial Conditions/CommentPrivileges in Pediatric CareManagement of routine pediatric care, including full-term newbornsSpecial Procedures for Level Three PrivilegesRequestedLevelSiteMedical Director ApprovalSpecial Conditions/CommentI hereby request the privileges identified above. Furthermore, I am physically and mentally capable to perform the above requested privileges.411480013589000013589000Applicant’s SignatureDate********The following recommendation is made to the Center Governing Board that has authority to grant or deny privileges.As Chief Executive Officer and Medical Director, we recommend that:Privileges for __________________________________ at the Center are: FORMCHECKBOX Approved FORMCHECKBOX Approved with Modifications FORMCHECKBOX Denied91440012636500Modifications: 03365500102870014795500Denial based on: 09271000400050013906500013906500Chief Executive Officer SignatureDate4000500679450008953500Medical Director SignatureDate ................
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