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AMDA Model Care Facility

Medical Staff Policies and Procedures

Policy Number: Admin.ADM.02

Subject: Physician Qualifications

Purpose: To maintain a procedure for credentialing and privileging independent licensed practitioners who render care in the Model Care Facility.

Rationale: See commentary, below.

Primary Responsibility: Medical Director

Scope: All facilities and special programs

Policy: The Medical Director shall recommend clinical privileges for independent licensed practitioners. Privileges granted by the Facility shall be appropriate to the care program of the Model Care Facility and shall be based on the practitioners' training, experience, demonstrated ability, and current competence. The Facility shall provide an appeal process for practitioners whose request for privileges is denied.


The process of obtaining, verifying, and assessing the qualifications of a health care practitioner to provide patient care services in or for a health care organization.
The process whereby a specific scope and content of patient care services (that is, clinical privileges) are authorized for a health care practitioner by a health care organization, based on evaluation of the individual's credentials and performance.


  1. The Model Care Facility shall verify the following credentials for all independent licensed practitioners in consideration of reviewing their initial application for clinical privileges or reapplication:
    • state medical license;
    • DEA certificate;
    • certificate of malpractice insurance
    • criminal background check
    • abuse registry check
    • professional references
    • personal statement of fitness with reasonable accommodations
    • questionnaire about disciplinary action, privilege restrictions, criminal violations, controlled substance violations, malpractice claims
    • query to the National Practitioner Data Bank.
  2. Practitioners may apply for clinical privileges at the Model Care Facility by providing required credentials information in writing and by requesting specified privileges:
    • Primary care (See Policy CAR.11)
    • Consultant care (See Policy CAR.12)
    • Procedures (specify)
  3. The Medical Director or designee will verify credentials information with the primary source, a JCAHO-accredited organization, or credentials verification organization.
  4. The Medical Director will recommend privileges to be granted or denied to the Facility Administrator [or Board of Directors]. The Administrator [or Board] will act on the Medical Director's recommendation and will inform the practitioner of the privilege action.
  5. The practitioner's privileges shall become effective upon signing of a Physician Agreement by the physician and Facility representative.
  6. Practitioners shall re-apply for privileges every 2 years.
  7. Any practitioner whose clinical privileges are denied or limited may appeal this decision to the Administrator.


  • Federal regulations (Tag): 483.40(a)(1-2) (Tag F385) Physician services; 483.55(a-d) (Tag F411-412) Dental services; 483.75(i) (Tag F501) Medical director
  • State regulations:
  • JCAHO standards: LD 3.1 - LD 3.1.2, HR 7 - HR 7.5

Other Facility Policies:

Key Words: Attending physician, Consulting physician, Credentialing, Dentist, Governing body, Independent licensed practitioner, Medical director, Medical staff organization, Podiatrist, Practice privileges

Author: Duncan S. MacLean, MD, CMD

Commentary: MacLean, DS, "Credentialing and Privileging: One Size Doesn't Fit All," Caring for the Ages, Vol. 2, No. 8, August 2001, p. 9-10. For more information or to subscribe, contact caring@lww.com.

Copyright: The author places this policy in the public domain. Attribution is requested.

Disclaimer: Use of this Policy is subject to the Terms of Use published on the AMDA Web site (www.amda.com). Neither AMDA nor the author assumes any responsibility for the consequences resulting from use of this model policy. Users are hereby advised to seek professional advice before implementing any policy.

Date Posted: October 2, 2001

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