Credentials and privileges are critical for ensuring that you have access to your patients and can practice to the full extent of your desired scope.
Hospital governing boards make decisions about privileges based on the organization's medical bylaws. One way that family physicians can protect family medicine's scope of practice is by ensuring a family physician representative is on the priviling committee.
Learn how to prepare for your credentials or privileges application process and how the AAFP can support you.
In order to submit your credentialing application, you will need to gather and submit documents that verify your training, education, experience, and licensure. Review the hospital’s medical staff bylaws thoroughly before requesting an application. Once your materials have been submitted, the hospital will verify the information you submitted and medical staff will review your application. The decision to grant or deny privilege(s) is an objective, evidence-based process.
To prepare for the credentialing or privileging process gather and make copies of these documents:
Request an application package from the medical staff office. Read and follow your hospital’s application instructions carefully. Submit all requested documents, including privilege request form(s) with your application. If information is missing or the medical staff requires more clarifying information, typically they send a letter requesting information within a specific time frame. If the information is not received within the specified time frame, the credentialing committee may consider the application withdrawn.
When you sign and submit the application, you attest the application and accompanying documents are accurate and complete. Any inaccuracy, omission, or misrepresentation, even unintentional, may be grounds for terminating the process. The applicant does not have the right to a fair hearing or appeal.
You also authorize hospital and medical staff to inspect all records and documents and consult prior and current references or others about your professional competence, character, ability to perform privileges requested, ethical qualifications, and professional liability actions.
The credentialing committee and medical staff appointee determines whether you meet privileging requirements. If so, your application is processed and verified. You may be asked for an interview. If an applicant does not meet requirements, a member of the credentialing committee will notify the applicant.
Be aware that medical staff bylaws may contain language stating that certain privileges may be reserved for a contracted group with exclusive privileges (i.e., anesthesia may have exclusive services for pain management/intraoperative anesthesia, or other procedures.) Thus, a physician may meet requirements, but it does not necessarily entitle them to privileges.
Privileging authorizes a physician to perform a specific scope of patient care.
Initial privileges are subject to a period of focused professional practice evaluation (FPPE). This period confirms current competence. After medical staff approval the credentialing committee will define how clinical performance is monitored and evaluated, this may use prospective, concurrent, or retrospective proctoring. Other evaluation may include:
Support your pursuit of privileges with help from the AAFP. These policies were written to help you advocate for the practice scope that fits your training. They can be provided as documentation in support of your request.