( 5) information concerning the applicant’ s professional liability litigation experience, including past, currently open claims or receipt of pending claims, final judgments, or settlements; the substance of the allegations as well as the findings and the ultimate disposition; and any additional information concerning such proceedings or actions as the Credentials Committee, the MEC, or the Board may request;
( 6) current information regarding the applicant’ s ability to safely and competently exercise the clinical privileges requested;
( 7) a list of all hospitals where the applicant has practiced or has applied for privileges;
( 8) information from any professional training programs including, but not necessarily limited to, residency and fellowship programs;
( 9) information from the National Practitioner Data Bank as well as any other applicable state or federal database regarding sanctions and exclusions;
( 10) other information about adverse credentialing and privileging decisions;( 11) information from a criminal background check;
( 12) information from any other sources relevant to the qualifications of the applicant to serve on the Medical Staff and / or hold privileges;
( 13) morbidity and mortality data and relevant practitioner-specific data as compared to aggregate data, when available;
( 14) verification of Social Security Death Master File; and( 15) a copy of a government-issued photo identification.
3. A. 2. Misstatements and Omissions:
( a) Any misstatement in, or omission from, the application, regardless of whether the individual’ s office staff completed the application or submitted the materials in question, is grounds to stop processing the application. The applicant will be informed in writing via the email address provided by applicant of the nature of the misstatement or omission and permitted to provide a written response within fifteen( 15) days. Failure to respond to the request for clarifying information may be considered as a voluntary withdrawal of the application. Should the applicant respond, the Chair of the Credentials Committee and CMO / VPMA will review the response and determine whether the application should be processed further.
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