Effective Date: 
Sun, 09/01/1996
Fri, 08/26/2011
Mon, 03/03/2014

To assure patients receive care by qualified clinical staff, each Nurse Practitioner (NP) or Physician Assistant (PA) must meet the credentialing requirements of Student Health Services prior to approval of clinical privileges.
The credentialing process involves verification of education, licensure, certification and reference checks.
Full clinical privileges for NP's and PA's require:

  • successful completion of the credentialing process,
  • review and signing of the Student Health Center Standardized Procedures and Protocols for Midlevel Providers, and
  • successful completion of a probationary period during which at least 30 charts are reviewed by the Medical Director.  

On-going clinical privileges are contingent on maintaining credentials.
It is the responsibility of the Medical Director with the assistance of the Assistant to the Director,  to obtain, review, and credential  NP's and PA's.
It is the responsibility of the Medical Director to maintain up-to-date Standardized Procedures and Protocols for Midlevel Providers. 


Initial Credentialing and Privileging:
1. NP/PA receives a credentialing form, privileging form and a copy of the Standardized Procedures and Protocols for Midlevel Providers (SPPMP) from the Assistant to the Director.
2. NP/PA completes the credentialing and privileging forms and returns them to the Assistant to the Director with copies of the following documents:

  • Current California professional license
  • Curriculum Vitae with two professional references
  • Current DEA certificate, furnishing number if applicable

3. NP/PA signs the Standardized Procedures and Protocols for Midlevel Providers.
4. Assistant to the Director verifies status of licenses and verifies credentials by querying the National Practitioner Data Bank (NPDB) and state licensing boards.
  The Assistant to the Director is the Credentialing Specialist and collaborates with a Credentialing Verification Organization (CVO) as needed.
5. Medical Director obtains at least two professional references. Medical Director is responsible for doing reference check.
6. Upon verification of credentials and background check, the Assistant to the Director provides the complete NP/PA credentialing file to the Medical Director.  After reviewing the file and request for clinical privileges, the Medical Director approves initial assumption of clinical duties with the indicated clinical privileges.  The NP/PA signs SPPML.
7. Initial review of clinical work is done on a minimum of 30 charts, but additional chart review may be deemed appropriate at the discretion of the Medical Director.  Results of the initial review will be evaluated by the Medical Director, who will hold a conference with the interim NP/PA regarding these results. At the conclusion of the period of initial review the Medical Director decides final approval of the NP or PA clinical privileges.
8. Documentation pertaining to the NP/PA's credentialing is maintained in a confidential credentials file in the office of the Assistant to the Director.
Procedure for Maintaining and Updating Credentials
1.  Regular file review will be done by the Assistant to the Director to identify anticipated expiration dates of credentials. 
2.  It is the responsibility of each NP/PA to provide copies of current license and credentials to the Student Health Services for their credentialing file. 
3. The Medical Director will review licensure documentation as well as an updated NPDB report, the results of peer review, quality monitoring information and any other relevant materials. 
4. Privileges for new or additional Clinical Procedures may be granted by the Medical Director at any time, upon submission of a written request which documents satisfactory training and experience appropriate to the procedure. The requesting clinician will be notified in writing of additional privileges granted, with copy for credentials file.