Guidelines for Release of Privileges & Credentialing Information
Form for Release of Information
Persons Permitted to Review Files
- A member of the clinical staff may review his/her credentials file.
- A department chair may review the credentials file of a member of the clinical staff of his/her department.
- The Chair of the Credentials Committee may review the file of any member of the clinical staff whenever the purpose is related to his/her role in the privileging/credentialing process.
- Staff of the Graduate Medical Education Office may review credentials files as necessary to carry out their job responsibilities.
- Internal auditors for the Commonwealth, the University, and the Medical Center may review files after a written request stating the purpose of the audit has been reviewed and approved by the Credentials Committee.
- Outside auditors for accreditation organizations, contractors or other government organizations may review files after a written request has been reviewed and approved by the Credentials Committee under the terms set forth by the Committee.
Rules for Review of Credentials Files
- Files may not be taken from the Graduate Medical Education Office. Authorized reviews of files will take place in the office.
- A staff person from the Graduate Medical Education Office must be present while any file is being reviewed.
- No information may be removed or copied from a file.
- Requests to remove of copy portions of a file must be approved by the Credentials Committee.
Requests for Information from Inside the Institution
- Any person or part of the Health Sciences Center or University may receive a listing of clinical staff members by department and specialty upon written request so long as such listing is to be used for University purposes.
- No other credentials file information will be sent without a written request stating the purpose of the information until the Credentials Committee has reviewed and authorized such request.
Requests for Information from Outside the Institution
- A member of the clinical staff may request in writing that specific privileging/credentialing information from his/her file be released to a designated third party.
- A third party contractor with the institution may request a copy of privileging/credentialing information in accordance with specified contract terms entered into with a component of the Health Sciences Center or one of its support foundations upon review and approval by the Credentials Committee.
- Information requested under court order will be released only after review and approval by the Credentials Committee and legal counsel.
- Privileging/credentialing information will NOT be released to any others without specific review and authorization by the Credentials Committee.
Rules for Release of Privileging/Credentialing Information
- All requests must be in writing with a copy of the request being placed in an individual's file and a master file for requests, except where the request is made by a third party contractor, in which case a copy will be placed only in the master file.
- All authorizations/approvals must be in writing and filed with the request in an individual's file and the master file.
- All information being sent out will be reviewed before being sent out to insure that no unauthorized or irrelevant information is included.
- The information sent out will be stamped CONFIDENTIAL on each and every page.
- Third party contractor information will include a statement that the information may only be used for privileging and credentialing UVa clinicians under a UVa contract.