Download-ready Word, Excel and fillable PDF starting points. Edit them to match your bylaws, policies, accreditor standards, state rules and payer contracts.
Step-by-step workflow from intake to committee: PSV, NPDB, OIG/SAM/state Medicaid exclusions, education & APP graduate education, peer references, privileges, file review, database entry, and sign-off. Fillable PDF or editable Word.
Who uses it: Hospital MSP
Letter and response form for a peer reference. It covers how long and in what role the reference has known the applicant ("Known applicant (From – To)", MM/YY), whether they worked directly together in the past 2 years, ratings on the six ACGME competencies, a recommendation on the privileges requested (attach a copy), conduct questions, signature and an office-use log.
Who uses it: Hospital MSP · Payor & CVO
Letter and response form asking a past employer or group to confirm dates (MM/YY), role, relationship type and standing. Includes an applicant work history summary and gap log based on NAMSS: history since training, at least the past 5 years, and a written explanation for gaps over 30 days.
Who uses it: Hospital MSP · Payor & CVO
A form for providers to list each gap of more than 30 days in education, training, work or affiliations (from and to in MM/YY), the reason, what you did during the gap and supporting documents, with a signed attestation. NAMSS ICS asks for a written explanation of gaps over 30 days.
Who uses it: Hospital MSP · Payor & CVO · Office & Group Enrollment
A one-stop list for physicians and APPs to gather before applying: identity and NPI, CV and work history (MM/YY, gaps over 30 days explained), education and training, licenses, DEA/CDS, board certification, malpractice COI and claims history, references, affiliations, life support, immunizations, CAQH ProView, case logs, CME, and APP agreements. Check each item, note expiration dates and keep it with your copies.
Who uses it: Providers · Office & Group Enrollment · Hospital MSP
Reappointment file checklist: practitioner details, file status, staff category, peers, privileges review, required certifications and forms, file review items, competency/OPPE and notes.
For requests to add privileges or a department: practitioner details, file status, required documents (DOP, protocol, case logs, license, DEA, NPDB, board, proctor) and audit.
Medical staff officer nominee checks: good standing, relevant privileges, board certification, adverse recommendations, license sanctions and other leadership roles.
Routing and sign-off sheet for a credentials file: request type, then action, comments, name, signature and date for department chair, Credentials Committee, MEC and governing board.
Evaluation form for files with issues: Medical Staff Office action, Department Chief action, MSS management review, Chief of Staff review and Credentials Committee action with signatures.
Credentialing / OPPE / FPPE audit form with Yes / No / N/A checkboxes for each file element. Available as a fillable PDF and an editable Word file.
A structural outline for a delineation-of-privileges request: core and special privileges, criteria, proctoring/FPPE and approvals.
Common disclosure questions (license actions, sanctions, health status, claims) with signature and date lines.
Pre-delegation and annual oversight review: delegation agreement, policies, file audit sampling and corrective actions.
Track each provider × payer application: submitted, follow-up, effective date, IDs and status, with drop-down statuses.
Letter and response form asking a hospital or other facility to confirm appointment dates, staff category, privileges, standing and adverse actions.
Letter and response form asking a medical school (or registrar) to confirm attendance dates, degree, graduation date and any adverse academic or professional actions.
Letter and response form for a GME program director or coordinator: program, dates, level, completion status, and any probation, remediation or disciplinary actions.
Letter and response form asking a malpractice carrier or patient compensation fund to confirm coverage (policy dates, limits, type) and provide claims history or a loss run.
Letter asking each carrier, self-insured program or patient compensation fund that insured the practitioner for a loss run: every claim and reported incident, open or closed, with or without payment.
Practitioner form listing coverage history (including tail, prior acts and gaps) and every claim, suit or settlement, with a signed attestation. Compare it with carrier loss runs and the NPDB.
Monthly LEIE, SAM and state-list screening log: who, what source, date, result and evidence location.
Log each call and email: date, payer, rep, reference number, outcome and next follow-up date.
