The following items are needed to begin the credentialing process:


____ Request for Clinical Privileges and Staff Appointment


____ Delineation of Privileges (DA Form 5440-series and DA Form 5440A) and search for Forms needed


____ Malpractice and Privileges Questionnaire (DA Form 5754)


____ Statement of Affirmation/Release of Information Statement


____ Two (2) Peer Letters of Reference (Statement of current competency, ability, character and health status.


____ Evidence of Peer Review (blood and/or drug utilization, procedures comparison to peers, etc.)


____ Degree


____ Internship Certificate


____ Residency Certificate


____ Fellowship Certificate


____ Board Certification Certificate


____ Current State License(s) License not required for Physician Assistant (PA) until 2009. PA we need National Certification Document

____ Initial License Certificate

____ Registration Card with Expiration Date


____ Department of Defense (DoD) Policy on Physician Licensure


____ Application for Request for Waiver of Administrative Licensure Requirements (if applicable)


____ Current Cardiopulmonary Resuscitation Care (BLCS)

____ Providers in Anesthesia need ACLS

____ Providers in ER need either ACLS or ATLS


____ Current Drug Enforcement Agency Registration (Federal and State)


____ Proof of Professional Liability Insurance (Active Duty Military are covered while on AD in MTF. Civilian Malpractice Document is nice to have.)


____ Curriculum Vitae


____ Off duty Employment Statement


____ Orders


Please forward the above to: Tripler Army Medical Center

ATTN: MCHK-QS (Credentials Office)

1 Jarrett White Road

Tripler AMC, HI 96859-5000


Current as of: 1 October 2005