Va Form 10-0376a - Credentials Transfer Brief Page 2
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1
2CERTIFICATIONS CONTINUED
CERTIFICATION NUMBER
EXPIRATION DATE
SUBSPECIALTY BOARD CERTIFICATION
TYPE OF CERTIFICATION
EXPIRATION DATE
BASIC CARDIAC LIFE SUPPORT (BCLS) &
7.
ADVANCED CARDIAC LIFE SUPPORT (ACLS)
CERTIFICATION
EXPIRATION DATE
CLINICAL PRIVILEGES GRANTED IN (Product Service Line) (Attach Copy)
8.
9.
NATIONAL PRACTITIONER DATA BASE QUERY(S) DATE:
10.
CLINICAL SUMMARY
attested to not having a physical
a.
(Provider's Name)
or mental health condition that would adversely affect the ability to carry out the clinical duties requested from
; is known to be clinically
(Name of the VA Medical Center or Health Care System where currently appointed)
competent to practice the full scope of privileges granted at this facility, to satisfactorily discharge professional and
, and is known to be providing
ethical obligations, as attested to by
(Name and telephone number of Service Chief)
does not have additional information relating to
has
or
telehealth services.
(Name of Service Chief)
competence to perform granted privileges.
(Provider's Name)
credentialing file and the documents contained therein have
b.
(Provider's Name)
been reviewed and verified as indicated above. The information conveyed in this memorandum reflects credential
. The credentialing file contains no additional information relevant to the privileging of
status as of
(Date)
at your Medical Center.
(Provider's Name)
REMARKS (Attach an additional sheet if necessary.)
11. TYPED NAME OF MEDICAL STAFF COORDINATOR
12. SIGNATURE OF MEDICAL STAFF COORDINATOR
13. TELEPHONE NUMBER
14. FAX NUMBER
15. PROVIDING FACILITY NAME
VA FORM
10-0376a
Page 2 of 2
JUL 2005
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