Attachment 1-Signature Page
180-01; 180-02; 180-06
UC DAVIS, STUDENT HEALTH AND COUNSELING SERVICES Provider groups* A & B
CREDENTIALING COMMITTEE RECOMMENDATION:
practitioner
Credentialing review:signature below indicatesthe credentialing file has been reviewed for accuracy of content, adherence to SHCS Policy & Procedures for credentialing, AAAHC Standards for credentialing, and identification of adverse information.
☐ Potential adverse information has been identified and flagged, OR N/A ☐
☐ Gaps in education, training and/or employment have been identified and flagged, OR N/A ☐
☐ Practitioner attestation, licenses and/or certificationsare current.
☐ Practitioner has cleared background check.
Additional Comments:
SHCS Credentialing OfficeDate
Medical Director (for medical/psychiatry) OR CS Director (for mental health) Recommendation:
The following signature indicates the Medical Director or CS Director (as applicable per practitioner specialty) has reviewed this credentialing file and recommendsapproval of the Credentialing Process for this individual.
☐ I have reviewed and evaluated potential adverse information. N/A ☐
☐ I have reviewed and evaluated gaps in education, training and/or employment.N/A ☐
☐ Practitioner is recommended for continuation of present privileges previously granted on ______
☐ Practitioner is recommended for approval of credentialing process and privileges (privileges review/approved separately).
☐ Practitioner is NOT recommended for approval of credentialing process (see comments below).
Additional Comments:
Top of Form
Bottom of Form
SHCS Medical Director or CS DirectorDate
CREDENTIALS COMMITTEE Review & Recommendation (members may review independent of a formal meeting):
as applicable:______- committee member initial/date ______- committee member initial/date
______- committee member initial/date ______- committee member initial/date
The following signature indicates the voting Credentials Committee Members have reviewed this credentialing file:
☐ have reviewed and evaluated potential adverse information. N/A ☐
☐ have reviewed and evaluated gaps in education, training and/or employment.N/A ☐
☐ Practitioner is recommended for continuation of present privileges previously granted on ______
☐ Practitioner is recommended for approval of credentialing process and privileges (privileges review/approved separately).
☐ Practitioner is NOT recommended for approval of credentialing process (see comments below).
Additional Comments:
Top of Form
Bottom of Form
Credentials Committee CHAIRDate
Governing Body or Designee approval: Signature below indicates that the Governing Body (or designee) has reviewed this credentialing file and approves the credentialing process for this individual.
☐ Practitioner’s credentialing reviewed and approved (privileges review/approved separately).
☐ Practitioner is NOTapproved(see comments below).
Additional Comments:
SHCS Executive Director, (Governing Body Designee)Date
The credentialing process has been approved and appointment is effective from ______to ______(not to exceed 3 years) with ongoing monitoring of all expiring licenses and certifications.
Category (For MD, DO, DPM only, circle one): Associate Active Consultant Courtesy
*Group A: LIP (MD, DO, DPM, PsyD, PhD) *Group B: AHP (NP, LCSW, MFT, Pharmacists, OD, PTs) 01/2016