The hospital collects information regarding each physician's or other licensed practitioner’s...

(1)

The governing body approves the credentialing process.

(2)

The hospital verifies that the physician or other licensed practitioner requesting approval is the same person identified in the credentialing documents by viewing one of the following: - Current picture hospital ID card - Valid picture ID issued by a state or federal agency (for example, a driver's license or passport)

(3)

The credentialing process requires that the hospital verifies in writing and from the primary source whenever feasible, or from a credentials verification organization, the following information for the applicant: - Current licensure at the time of initial granting, renewal, and revision of privileges and at the time of license expiration - Relevant training - Current competence

(4)

The medical staff examines the credentials of all candidates eligible for medical staff membership and makes recommendations to the governing body on the appointment of these candidates, in accordance with state law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations. Note: For hospitals that use Joint Commission accreditation for deemed status purposes: A candidate who has been recommended by the medical staff and who has been appointed by the governing body is also subject to 42 CFR 482.22(a).

(5)

For hospitals that use Joint Commission accreditation for deemed status purposes: A full-time, part-time, or consulting radiologist, who is a doctor of medicine or osteopathy qualified by education and experience in radiology, supervises ionizing radiology services and interprets radiologic tests that the medical staff determine to require a radiologist’s specialized knowledge.