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