Credentialing & Privileging

Tip of the week: Know the key elements of a credentialing acknowledgement form

Credentialing Resource Center Connection, September 3, 2009

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The following are the key elements of a credentialing acknowledgement form:

  • Applicant acknowledges that acceptance of the application by any entity does not constitute a contractual agreement for employment, membership, or granting of privileges.
  • Applicant acknowledges that as a member, he or she is required and pledges to provide continuous care for his or her patients.
  • Applicant acknowledges that the burden of producing requested documentation to support his or her application for initial and ongoing eligibility for membership or participation is the responsibility of the applicant.
  • Applicant acknowledges that misstatements or omissions from the applicant may constitute cause for denial or revocation of membership or appointment.
  • Applicant consents and authorizes (if applicable) the entity to procure a consumer report, which may include (but is not limited to) the following information:

         - Records and information related to criminal history or federal sanctions, including but not limited to convictions, deferred adjudication, probated sentences, warrants, and other types of changes
        - Medicare and Medicaid sanctions
        - Social Security verifications
        - Motor vehicle records
        - Previous address information

    This week’s tip is from The Credentialing Coordinator’s Handbook, by Anne Roberts, CPMSM, CPCS.



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