Biographical sketch, kathy matzka, cpmsm, cpcs

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Verification of Application Information

The healthcare organization is obligated to assure that only competent practitioners provide treatment and services to its patients. This is accomplished through verification of the information provided by the practitioner and assuring that the practitioner meets the requirements for membership and privileges.

Primary Source

A primary source is the original source that can verify the accuracy of a credential, qualification, or other information reported by the practitioner. For instance, when seeking to verify completion of a residency program, the organization contacts the residency program and asks for this verification.
Primary source verification can be performed via letter, fax, approved official website, or well-documented telephone call. If verifying by phone, include the name of the organization called, the date, the person contacted, the questions asked, the response, the name of the person receiving the response.

Education and Training

Undergraduate education (school, year of graduation) is not typically verified unless privileges requested correspond with the training received. Hospitals should verify accredited medical school completion. In the managed care setting, the MCO must verify the highest of the following three levels of education and training obtained by the practitioner: (1) graduation from medical or professional school, (2) residency, or (3) board certification. Medical school completion is typically verified through direct contact with the school or by AMA or AOA profile for US graduates and ECFMG for foreign medical graduates.

Postgraduate training including internship, residency, and fellowship should be verified. In addition to completion of this training, a hospital will request information about the quality of an applicant’s work and clinical competence from an internship, residency, or fellowship program in order to verify competency and ability to perform privileges. Any specialized training outside the residency or fellowship that reflects on the applicant’s privileges should be verified.

Options for Verification of Education and Training
Relevant training or experience is defined by the specific circumstances of the applicant. This may vary among specialties. The hospital must believe there is sufficient information on which to base a reasoned decision. Verification can come from:

  • the school;

  • American Medical Association (AMA) Physician Masterfile (for physician);

  • A credentials verification organization;

  • Educational Commission for Foreign Medical Graduates (ECFMG) for verification of graduation from a foreign medical school;

  • American Osteopathic Association (AOA) Physician Database for predoctoral education accredited by the AOA Bureau of Professional Education.

  • American Medical Association (AMA) Physician Masterfile; and

  • (AOA) Physician Database for postdoctoral education approved by the AOA Council on Postdoctoral Training

Medicare CoP Regarding Verification of Education and Training
The governing body ensures that the criteria for selection of both new medical staff members and selection of current medical staff members for continued membership must be based on individual character, competence, training, experience, and judgment.

Sample Letter for Verification of Training

Re: [Applicant’s full name, Title]

Training: [Residency/fellowship]

Specialty: [Specialty]

Dates: [From/to]
Dear [Program Director name]:
We have received an application from the above-named provider for medical staff appointment and/or privileges. A copy of the privileges requested is attached. The applicant noted that the above-specified training took place at your institution. In order to process the application we require verification of completion of training and documentation of experience, ability, and current competence on the six areas of “General Competencies” adopted from the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) joint initiative.
Our policies require completion of the enclosed form. Failure to receive this form will delay consideration of the applicant’s request for privileges. Also, our policies require the physician to document competency in performing specific procedures by allowing our organization to obtain a copy of his/her procedure list from your program and the outcomes for those procedures (if outcomes are available). The applicant has authorized you to provide this information to our organization via signature on the attached Authorization and Release Form.
Enclosed is a copy of a release and immunity statement signed by the applicant consenting to this inquiry and your response. The immunity statement releases from liability any individual who provides the requested information.
Thank you for your assistance. We look forward to hearing from you.
Residency Program Director’s Evaluation and Recommendation

Page 1

Re: [Applicant’s full name]

Training: [Residency/fellowship]

Specialty: [Specialty]

Dates: [From/to]

Area of Evaluation

Please use comment section below to provide additional information noting question number for which information is provided.



Unable to Evaluate


Were you the director of the program at the time of this applicant’s training?


Was the applicant at your institution in the above program for the stated period of time?


Was the program fully accredited throughout the applicant’s participation in it?


Did the applicant successfully complete the program?


Did the applicant receive satisfactory ratings for all aspects of his/her training in the program?


Was the applicant ever subject to or considered for disciplinary action?


Did the applicant ever attempt procedures beyond his/her assigned training protocols?


Was the applicant’s status and/or authority to provide services ever revoked, suspended, reduced, restricted, not renewed, or was he/she placed on probationary status or reprimanded at any time or were proceedings ever initiated that could have led to any of the actions?


Did the applicant ever voluntarily terminate his/her status in the program or restrict his/her activities in the program in lieu of formal action or to avoid an investigation?


In reviewing the attached request for privileges, do you feel that the applicant’s training and experience included these procedures?


In reviewing the attached request for privileges, do you feel that the applicant is currently competent to carry out these procedures?


Are you aware of any physical or mental condition that could affect this practitioner’s ability to exercise clinical privileges in his/her specialty area, or would require an accommodation to exercise those privileges safely and competently?

Question Comment

_______ __________________________________________________________

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Residency Program Director’s Evaluation and Recommendation

Page 2

Re: [Applicant’s full name]

Training: [Residency/fellowship]

Specialty: [Specialty]

Dates: [From/to]
Please rate the applicant in each of the following areas:





Unable to


Patient care

Medical knowledge

Practice-based learning and improvement

Interpersonal and communication skills


Systems-based practice

This evaluation is based upon:
 Personal knowledge of the applicant.
 Review of file.
 Other _____________________________________________________________________________
Overall Recommendation (check ONE):
 I recommend privileges as requested without reservation.
 I recommend privileges as requested with the following reservation(s) (use back of form, if necessary


 I do not recommend this applicant for the following reason(s) _____________________________________________________________________________________________
_______________________________________ _____________________________

Signature Date

_______________________________________ _____________________________

Name, Position/Title (Please Print) Phone Number

Please return this form within 2 weeks. Failure to receive the form will delay consideration of the applicant’s request for privileges.
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