CREDENTIALING CHECKLIST

(RESERVE)

 

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)

      http://www.usapa.army.mil/    and search for Forms needed

 

____  Malpractice and Privileges Questionnaire (DA Form 5754)

      http://www.apd.army.mil/pub/eforms/pdf/a5754.pdf

 

____  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