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MCN ToolBox Entries

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Credentialing & Privileging Policy

Health Center credentialing and priviliging policy statement.
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Employee TB Skin Test

Sample policy on employee TB skin testing.
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Scope of Medical Practice

Outline of scope of medical practice guidelines.
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Request for Clinical Privileges

The intent of this privilege list is to aid in evaluating the abilities and training of applicants and as a general guide to the level of functioning of that provider.

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Primary Source Verification for Clinical Providers

The initial credentialing process must include primary source verification of graduation from an accredited professional school and residency training program and a query of the National Practitioner Data Bank. This outlines the policy and provides a release of information form.

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Practitioner Checklist for Reappointment

Checklist of requirements for any practitioner reappointment. Recommended that it be filled out every two years following initial appointment.

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Physician Checklist for Initial Appointment

Checklist that outlines requirements for any physician’s initial appointment to the health center.

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Delineation of Privileges in Family Practice Ambulatory Care

Checklist of Delineation of Privileges in Family Practice Ambulatory Care for applicants or new hires.

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Delineation of Privileges in Ambulatory Care

Checklist of Primary Care Practitioner privileges in ambulatory care for use with any applicants or new hires.

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Clinical Subcontractor Report Form

This form should be filled out annually by any clinical subcontractors. It outlines licensing, appointment certification and credentialing for any clinical staff that provides services under the subcontract.
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