Name of procedure/privilege_________________________________________
Education required to request privilege (check all that apply)
MD - Medical Doctor
DO - Osteopathic Physician)
DDS - Oral and Maxillofacial Surgeon
DMD - Dentist
DPM - Podiatrist
APN – Advance Practice Nurse (specify specialty)______________________________
PA – Physician Assistant (specify specialty) ___________________________________
DC – Chiropractic
Other (specify) __________________________________________________________
CME Board Certification
Manufacturer’s Training Course/Certificate Peer Recommendations
Is monitoring or proctoring required?
If yes, specify the following:
Number of procedures ___________ Length of time __________________
In order to complete proctorship/monitoring requirements, the applicant must perform
_______ (number) procedures within _____________(time frame).
What type of review or follow up will be conducted?
Structured Interview Questions
Education, Training, Experience, and Current Work Practice and Experience
Briefly explain your educational background and training.
Do you have any specific areas of interest or expertise? If so, explain.
Are there any areas of your practice for which you anticipate the hospital would need to purchase additional equipment or would require additional training of staff should the hospital choose to provide these services?
1. Please describe the various health care delivery settings and systems in which you will be participating. (i.e. outpatient surgical centers, other hospitals, etc.).
2. Describe how membership on the medical staff of [Hospital name] will develop or build your practice.
3. What percentage of your patient practice do you anticipate will be performed at [Hospital name]?
4. Describe your anticipated use of consultants.
5. Would you be available to provide patient education by participating in educational presentations, development of educational materials, etc?
Understanding of Bylaws Requirements
(List key issues the medical staff or hospital feel need to be reinforced.)
1. Do you understand that the bylaws require you to provide for alternate coverage? Please describe the arrangements you have made for alternate coverage.
2. Do you understand that the bylaws require continuous professional liability coverage of at least $1 million per claim and $3 million annual aggregate and if claims made insurance is purchased, you must provide for the purchase of "tail coverage" or "nose coverage"?
3. Do you understand your responsibility for participating in the call rotation for providing care to unassigned patients who present through the emergency department?
4. Do you understand the requirements for completion of medical records including automatic suspension provision for incomplete records over ___ days old?
Follow-up of Information Received in Application Process
(List any issues identified in the application process that require clarification or discussion.)
1. Please discuss the details of any malpractice claims that have been filed against you.
2. A letter received from one of the hospitals you practiced at it the past documents that you experienced a chronic problem with timely completion of medical records. Please describe the steps you are taking to assure this does not happen at [Hospital name].
3. You noted in your application that you are not board certified. Have you applied to take the exam? Have you taken the exam and failed?
4. You seem to have changed practice locations a number of times; can you explain the reason for these moves
Sample language for medical staff minutes:
“Committee members reviewed the applications, the supporting documentation, the Department Chairmen’s recommendations, and information received during the credentialing and privileging processes [or insert OPPE/FPPE etc., as appropriate]. Based on this review, it is the committee’s opinion that the following applicants meet the requirements for Medical Staff appointment and have documented appropriate education, training, experience, current competency, clinical judgment, professionalism, and health status to perform the privileges requested. It was moved, seconded, and carried to recommend to the [fill in Credentials Committee or MEC as appropriate] approval of the following appointments and clinical privileges [or insert cessation of FPPE, etc]:”
Sample language for Board minutes:
“Board members reviewed the applications, the supporting documentation, the Department Chairmen’s recommendations, Medical Executive Committee’s recommendations, and information received during the credentialing and privileging processes [insert OPPE/FPPE etc., as appropriate]. Based on this review, it is the Board’s opinion that the following applicants meet the requirements for Medical Staff appointment and clinical privileges [insert cessation of FPPE etc., as appropriate] as recommended and it was moved, seconded, and carried to approve of the following appointments and clinical privileges [insert cessation of FPPE, etc]:”
Recommendation and Approval Form for Medical Staff Appointment and Clinical Privileges
Staff Status:__________________ Department:_____________________ Specialty:_________________________
Based on the evaluation of the education, training, current competence, health status, skill, character, and judgment of the applicant the following recommendations are made:
Privileges be granted/renewed
Medical staff membership be granted/renewed
Additional privileges requested be granted
Privileges be modified as follows: _________________________________________________________________________
Privileges not be granted/renewed
Medical staff membership not be granted/renewed (comment below)
Additional privileges requested be denied (comment below)
Department Chairman Date
Credentials Committee Recommendation
Based on the evaluation of the education, training, current competence, health status, skill, character, and judgment of the applicant and on the evaluations and recommendations of the Department Chairman the following recommendations are made:
Concur with recommendation(s) of the Department Chairman and forward these recommendations to the Medical
Do not concur with the recommendations of the Department Chairman, and instead make the following recommendations:
Credentials Committee Representative Date
Medical Staff Executive Committee Recommendation
Based on the evaluation of the education, training, current competence, health status, skill, character, and judgment of the applicant, and on the evaluations and recommendations of the Department Chairman and Credentials Committee, the following recommendations are made:
Concur with recommendation(s) of the Department Chairman and Credentials Committee and forward these
recommendations to the governing body for consideration.
Do not agree with the recommendations of the Department Chairman, and Credentials Committee and instead make the
following recommendations: _________________________________________________________________________
Medical Staff Executive Committee Representative Date
Governing Body Approvals/Action Taken
Based on the evaluation of the education, training, current competence, health status, skill, character, and judgment data and information, and on the recommendations of the Medical Staff, the following action is taken:
Concur with and approve the recommendation(s) of the Medical Staff.
Do not concur with the recommendations of the Medical Staff. Action taken is documented in Board minutes of ________________.
Board of Trustees Representative Date