Fillable Printable VA Form 10-0376a

VA Form 10-0376a

VA FORM

JUL 2005

10-0376a

OMB Number: 2900-0621

Est. Burden: 1 hour

CREDENTIALS TRANSFER BRIEF

The Paperwork Reduction Act of 1995 requires us to notify you that this information is collected in accordance with the clearance requirements of section 3507 of the

Paperwork Reduction Act of 1995. The public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for

reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. No person

will be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Submission of this

information is voluntary and failure to respond will have no adverse effect on any benefits to which you otherwise may be entitled.

NOTE: Any item not verified at the primary source is listed with notation of information substituted.

1. IDENTIFYING DATA

NAME (Last, First, Middle Initial)

SOCIAL SECURITY NUMBER

TYPE OF APPOINTMENT SPECIALTY

State

2. EDUCATION AND TRAINING

Residency

Fellowship

Degree or

Specialty

Institution Location

Completion

Date

Primary

Source

Verified

4. STATE MEDICAL LICENSE

ISSUE DATE

CERTIFICATE NUMBER VERIFIED

License

Type

3. ECFMG

License

Number

Expiration

Date

STATE DANGEROUS CONTROLLED

SUBSTANCE (CDS)

Primary

Source

Verified

SPECIALTY

CERTIFICATIONS

EXPIRATION DATE

CERTIFICATION NUMBER EXPIRATION DATE

Education

Internship

SPECIALTY BOARD CERTIFICATION

The information requested is solicited under Title 38, United States Code, Chapters 73 and 74. This is collected primarily to determine your qualifications and suitability for

employment. If you are employed by the VA, the information will be used to make pay and benefit determinations and, as necessary, in personnel administration processes

carried out in accordance with established regulations and published notices of systems of records. Information may be released without your prior consent where authorized

by Title 38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where required by other statute outside the VA to another Federal, State or local agency, to the National

Practitioner Data Bank which is administered by the Department of Health and Human Services, to State licensing boards, the American Medical Association, Federation of

State Medical Boards, and/or appropriate professional organizations or agencies to assist the VA in determining your suitability for hiring and for employment, to periodically

verify, evaluate and update your clinical privileges and licensure status, to report apparent or potential violations of law, to provide statistical data upon proper request, or to

provide information to a Congressional office in response to an inquiry made at your request. Such information may also be released without your prior consent to Federal

agencies, State licensing boards, the Federation of State Medical Boards, or similar boards or entities, in connection with the VA's reporting of information concerning your

separation or resignation as a professional staff member under circumstances which raise serious concerns about your professional competence. Information concerning

payments related to malpractice claims and adverse actions which affect clinical privileges also may be released to State licensing boards and the National Practitioner Data

Bank. The information you supply may be verified through a computer matching program at any time.

Privacy Act and Paperwork Reduction Act Information

EXISTING STOCK OF VA FORM 10-0376a, FEB 2002, WILL BE USED.

Page 1 of 2

VA FORM

JUL 2005

10-0376a

TYPE OF CERTIFICATION

BASIC CARDIAC LIFE SUPPORT (BCLS) &

ADVANCED CARDIAC LIFE SUPPORT (ACLS)

CERTIFICATION

10.

CERTIFICATION NUMBER

CERTIFICATIONS CONTINUED

EXPIRATION DATE

CLINICAL PRIVILEGES GRANTED IN (Product Service Line) (Attach Copy)

SUBSPECIALTY BOARD CERTIFICATION

NATIONAL PRACTITIONER DATA BASE QUERY(S) DATE:

EXPIRATION DATE

CLINICAL SUMMARY

11. TYPED NAME OF MEDICAL STAFF COORDINATOR 12. SIGNATURE OF MEDICAL STAFF COORDINATOR

15. PROVIDING FACILITY NAME

13. TELEPHONE NUMBER 14. FAX NUMBER

Page 2 of 2

(Provider's Name)

attested to not having a physical

or mental health condition that would adversely affect the ability to carry out the clinical duties requested from

(Name of the VA Medical Center or Health Care System where currently appointed)

; is known to be clinically

competent to practice the full scope of privileges granted at this facility, to satisfactorily discharge professional and

ethical obligations, as attested to by

(Name and telephone number of Service Chief)

, and is known to be providing

telehealth services.

(Name of Service Chief)

has does not have

additional information relating to

competence to perform granted privileges.

(Provider's Name)

credentialing file and the documents contained therein have

been reviewed and verified as indicated above. The information conveyed in this memorandum reflects credential

status as of

(Provider's Name)

(Date)

. The credentialing file contains no additional information relevant to the privileging of

(Provider's Name)

at your Medical Center.

REMARKS (Attach an additional sheet if necessary.)