a . Medical Staff Officers shall have access to all Medical Staff records . b .
Medical Staff Department and Section Chiefs shall have access to all Medical Staff records pertaining to the activities of their respective sections .
c . Consultants ( who may or may not be Members of the Medical Staff ) reviewing a practitioner ’ s performance at the request of a Medical Staff committee or section shall have access to the credentials and peer review files of the practitioner being reviewed and any other pertinent Medical Staff committee records . d .
The CEO , the CMO / VPMA , and the Chief of Staff shall have access to all Medical Staff records .
2 . General Access by Practitioners to Medical Staff Records . a .
b .
Credentialing and Peer Review Files . A practitioner shall have the right to copies of any document in his or her own credentialing and peer review files that he / she submitted or filled out on behalf of Renown , ( i . e ., his or her application , reapplication , privileges list , or correspondence from him or her ) or that were addressed directly to the practitioner . A practitioner shall not be allowed access to any further information in his or her credentialing and quality file without a subpoena or on advice of Renown legal counsel .
Medical Staff Committee Files . A practitioner shall be allowed access to Medical Staff committee files ( to include committee minutes ) only if , they are a member of the committee or were at the time of the minutes or following a written request by the practitioner that is approved by the MEC and the Board of Governors , for good cause or as directed by Renown legal counsel .
3 . Access by Outside Persons or Organizations . a . Credentialing Or Peer Review At Other Hospitals .
( 1 ) Routine Requests for Information . If a practitioner has not encountered disciplinary or peer review problems or been denied privileges at the Hospital , the CEO , the CMO / VPMA , or Chief of Staff may release information contained in the practitioner ’ s credentials and peer review file in response to a request from another Hospital or its medical staff . Such requests must include notification that the practitioner is a member of that Hospital ’ s medical staff ,
4879-7702-4986 , v . 1 28