IMPORTANT CREDENTIALING INFORMATION – READ THOROUGHLY
Thank you for your interest in applying to be credentialed at a Fairview entity. The Fairview System
Credentialing Office (FSCO) provides credentialing verification services to the hospitals and clinics within
Fairview Health Services as well as Behavioral Healthcare Providers and Fairview Physician Associates.
In order to begin the application process, please provide the information listed on the attached Application
Checklist to the FSCO within 10 days of receiving this letter. Please only apply to the Fairview entity(ies)
where you intend to see patients. Most Fairview entities have monetary dues that you will be required to
pay if appointed to their medical staff.
Please note that only complete applications will be processed. All blanks on the application form must be
completed legibly, all forms and addendums signed, and all required accompanying information submitted
with the application. Incomplete applications are returned to the applicant which causes delays. Applicant’s
direct email address is required for confidential correspondence. Your direct email address will be used by the FSCO,
Medical Staff Office and for other essential communications.
The credentials verification process involves primary source verifying (i.e., sending letters directly to the
source) all of the information on the application. The length of time to complete your application is mainly
dependent on the timely response to our letters from these verification sources. Please note that the time
frame to complete your application may be longer if you have any military history, or international training
or education because of the logistics in verifying this information. In an effort to shorten the processing
time for your application, you are encouraged to contact the sources listed on your application and ask
them to return Fairview’s verification requests as soon as possible.
Please note: your application will not be considered complete and will not be sent to entity for
review/approval until proof of immunization compliance is documented.
Use the attached PROFESSIONAL STAFF
APPLICATION CHECKLIST as a guide when
completing your application and to assure that
the application is complete
You may review your application and information from publicly available documents at any time
during the verification process. If there are discrepancies in the information received during the
process, you will be allowed an opportunity to provide corrected information.
As part of its service to practitioners, FSCO provides delegated credentialing services to health plans and
provider networks. When you apply to a Fairview entity, you accept certain conditions regarding
immunities and authorizations to obtain or release information, including the release of information to
these health plans and provider networks.
Again, thank you for your interest in Fairview Health Services. If you have any questions or concerns
about the application process, please contact the FSCO at 612-672-7700 and choose Option 1 for Initial
Applications.
Initialahpcoverletter2013.doc
PROFESSIONAL STAFFAPPLICATION CHECKLIST
Use this checklist when completing your application to ensure all materials
are submitted correctly. INCOMPLETE APPLICATIONS WILL BE RETURNED
WHICH DELAYS YOUR CREDENTIALING PROCESS.
□ Uniform Application Form
● Complete the application form with your name as listed on your MN license to practice.
All blanks must be legibly completed. Full addresses, email, phone and fax numbers are required.
● List both month and year when completing “to/from” date blanks.
● Peer references – only one can be a current office associate and at least one must have the same education/degree
as you (for example, PA=PA, NP=NP, RN=RN, LICSW=LICW, etc.). Peer references should be professionals who
have current knowledge of your skills, abilities, judgment, professional performance, and clinical competence within
the past 24 months. Include your collaborative or sponsoring physician (if applicable).
● Explanations are required for “Yes” answers to Disclosure Questions and time gaps greater than 6 months.
● Sign and date application form and all addendums.
● Solo practices or clinics/practices that have closed – include name, address and phone number of someone who can
verify the time you practiced there.
● Locum tenens – include name, address and phone number of locum tenens company(ies) and clearly indicate which
assignments were performed for which locums company.
□ Collaborative Agreement or Sponsorship Form(s)
● Form must be completed if you are in a category that requires a collaborative physician or sponsoring physician (as
outlined in the application).
● Your collaborative/sponsoring physician must be a medical staff member of the entity(ies) to which you are applying.
● Your collaborative/sponsoring physician must complete, sign and date all indicated areas on the form.
□ Minnesota Background Study Authorization Form
● Sign and date form titled “Disclosure and Authority to Release Information”.
□ $200 Application Fee
● Complete credit card payment form or make check payable to Fairview System Credentialing and send with
application.
□ Copy of Current Professional Liability Insurance Certificate
● Certificate must include practitioner’s name, insurance company’s name and address, policy number, expiration date
and coverage amount (minimum of $1 million/3 million in professional liability insurance coverage).
□ Copy of Current License and/or Certification (if applicable)
●
Expiration date must be clearly listed on copy.
□ Copy of Current DEA Certificate (if applicable)
□Statement of valid Visa status (if not a U.S. citizen)
●
If you are not a United States citizen Fairview policy requires an affirmation statement from you indicating you have a valid work permit
or visa allowing work in the United States. Please confirm your status by providing a written response. (no other documentation is
necessary).
□ Immunization Documentation Form – Not required if you are ONLY applying to Behavioral Healthcare Providers
(BHP), Fairview Physician Associates (FPA) or Crosstown Surgery Center (CSC); form must be submitted if you want to work at
any Fairview hospital or clinic
● Complete the enclosed forms and fax to Employee Occupational Health Services (EOHS) at the fax number listed on
the form. Call EOHS staff at 612-672-4602 if you have questions regarding completion of the form or Fairview’s
immunization requirements.
● Please do not submit your personal immunization health records to the Fairview System Credentialing Office.
Please note: your application will not be considered complete and will not be sent to entity for review/approval until
proof of immunization compliance is documented by EOHS.
□ Privilege Form or Scope of Practice Form
● Sign and date form(s).
● Check privileges or scope requested only for the Fairview entity(ies) where you intend to see patients.
● Some procedures request documentation of training and/or experience. These procedures are noted on the form.
Required documentation must be submitted with application. If not submitted, your request will be considered
voluntarily withdrawn.
Revised 8/2/2013
Notice Regarding Accommodating Deaf or Hard of Hearing Patients
If you recognize or have any reason to believe that a patient, relative or close friend or companion of a patient is
deaf or hard of hearing, you must advise the person that auxiliary aids and services will be provided free of
charge. These aids and services include sign language and oral interpreters, TTYs, note takers, written materials,
telephone handset amplifiers, assistive listening devices and systems, telephones compatible with hearing aids,
closed caption decoders and open and closed captioning of most hospital programs.
If you are the responsible health care provider, you must take reasonable and necessary steps to ensure that such
aids and services are provided when appropriate. All other hospital personnel should direct that person to
interpretive services.
For metro assistance, contact interpretive services at 612-273-3780.
For assistance at Fairview Lakes Medical Center, Wyoming, MN
8 a.m to 4:30 p.m.: call 651-982-7850
evenings/weekends: call 612-526-0291
TTY: call 651-982-7339
For assistance at Fairview Northland Medical Center, Princeton, MN
8 a.m. - 4:30 p.m.:
call 763-389-6345
pager 612-613-5116
evenings/weekends:
1-320-259-9239 or 1-877-456-7589
This advice and offer must also be made in response to requests from patients and their families for auxiliary
aids or services.
Initial Application Request Form
Instructions: To request initial membership and/or privileges at a Fairview entity, please complete and submit the
information below in addition to the initial application, privilege form(s) and required documentation (if applicable) to:
Fairview System Credentialing Office - Initial Applications, 2344 Energy Park Dr, Ste 127, St Paul, MN 55108 or fax to (612)
672-4123.
Applicant Name:
____________________________________________________________________________________________________
Last
First
Middle
Suffix
Title
Fairview Entity(ies) Initial Application Request Applies to: (check all that apply)
 Fairview Clinics
 Fairview Ridges Hospital
 Fairview Lakes Medical Center
 Fairview Southdale Hospital
 Fairview Northland Medical Center
 University of Minnesota Medical Center, Fairview
 Fairview Physician Associates*
 Crosstown Surgery Center
 Behavioral Healthcare Providers*
 Fairview Maple Grove Ambulatory Surgery Center
*Please note that Behavioral Healthcare Providers and Fairview Physician Associates do not require privilege forms.
Primary Fairview Hospital?
If you are applying to more than one Fairview hospital, please indicate below which hospital is your primary Fairview hospital.
_________________________________________________________________________________
Preferred direct e-mail address:
Please provide the e-mail address you prefer to be used for credentialing purposes and for other Fairview purposes if a legitimate need has been identified
with the understanding it is not for publication or distribution to other organizations or individuals.
__________________________________________________________________________________________________________________________
Special Request Privileges:
Are you requesting any Special Request Privileges as listed on the privilege form?  Yes
 No
If yes, please select one of the following:
 Required documentation is attached (see requirements listed on the privilege form)
 Required documentation will be submitted at a later date.**
** Please note that special request privileges cannot be processed until the Fairview System Credentialing Office receives
required documentation.
The following items are required when submitting your request for initial credentialing:








Initial Application Request Form
Initial Application
Privilege Form*
Special Request Privileges Documentation** – if applicable (see above)
Explanations for any “YES” answers on Disclosure Questions
Fairview Authorization and Release
Disclosure and Authority to Release Form (MN Background Study)
Application Fee
Disclosure and Authority to Release Information
I understand that in processing my credentialing application for a Fairview entity, Fairview Health
Services is required by Minnesota Statute Chapter 245C to electronically submit a background study
request to the Minnesota Department of Human Services.
I authorize Fairview Health Services to use the information from my initial credentialing application to
submit the background study to the Minnesota Department of Human Services.
I may request my privacy rights, which are outlined in a notice entitled “Background Study Privacy
Notice” from Fairview Health Services or by calling (651) 296-3971.
Full Name ________________________________________________________
(please print)
Signature_________________________________________________________
Date Signed _______________
Fairview System Credentialing
AUTHORIZATION AND RELEASE
I understand and acknowledge that, as an applicant for membership, participation and/or clinical privileges (hereinafter, referred to as
“Participation”) at Fairview Health Services and/or at any subsidiary or affiliate of Fairview Health Services for which I apply for Participation
(hereafter referred to as Entity), it is my responsibility to provide sufficient information upon which a proper evaluation can be undertaken of my
current licensure, relevant training and/or experience, current competence, health status, character, ethics and any other criteria adopted by the
Entity for Participation.
I further acknowledge that I am responsible for knowing the contents of the applicable bylaws, rules and regulations, and req uirements of the
Entity and its professional/medical staff/network, and agree to be bound by them in the application process and if granted Participation.
I further understand and acknowledge that the Entity, its designated agent(s) and/or other authorized representatives, including, without limitation,
the Entity’s designated professional credentials verification organization (CVO), collectively referred to as “Agents”, will investigate the information
in this Application. By submitting this Application, I agree to such investigation and to the disciplinary reporting and information exchange
activities of the Entity and its Agents as follows:
1.
2.
3.
Authorization of Investigation and Release of Information Concerning Application for Participation. I authorize the Entity and its
Agents to consult with any third party who may have information bearing on my professional qualifications, credentials, clinical competence,
character, mental condition, physical condition, alcohol or chemical dependency diagnosis and treatment, ethics, behavior, or any other
matter reasonably having a bearing on my qualifications for Participation and authorize such third parties to release such information to the
Entity and its Agents.
Authorization of Release and Exchange of Disciplinary Information. I hereby further authorize any health care organization at which I
have applied for, currently have or had Participation or employment to release Disciplinary Information about any disciplinary action taken
against me to the Entity and/or its Agents, including, without limitation, the CVO, and as otherwise may be required by law. I hereby further
authorize the CVO to release Disciplinary Information about any disciplinary action taken against me to its participating entities at which I
have Participation, and as otherwise may be required by law. As used herein, Disciplinary Information means information concerning (i) any
action taken by such health care organizations, their administrators or their medical or other committees to revoke, deny, suspend, restrict or
condition my Participation or impose a corrective action plan; (ii) any other disciplinary actions involving me including but not limited to
discipline in the employment context; or (iii) my resignation prior to the conclusion of any disciplinary proceedings or prior to the
commencement of formal charges but after I have knowledge that such formal charges are contemplated and/or in preparation.
Release from Liability. I hereby further release from liability the Entity and its Agents, state licensing board(s), health care organizations,
including, without limitation, hospitals, clinics, and third party payers, medical malpractice insurance carrier(s), and any staff, and all
individuals, institutions and entities providing information in accordance with this authorization, for their acts performed in good faith and
without malice in connection with the gathering and release and exchange of information as consented to above. This release shall be in
addition to any other applicable immunities provided by law for peer review activities.
I understand that communication regarding my application may occur via email.
I understand that if I am an employee of Fairview Health Services or any of its subsidiaries, an employee of University of MinnesotaPhysicians, a
member physician of Fairview Physician Associates Network and/or a member of the Behavioral Healthcare Providers network, that Fairview
Health Services has entered into delegated credentialing agreements with certain health plans for purposes of streamlining and expediting my
credentialing with those health plans. Without this delegation in effect, I would be required to sign this same authorization and release when
applying for credentials directly to the payor. Accordingly, I hereby understand and agree that the terms of this authorization and release shall be
interpreted to authorize the release of parts of my credentialing application to such health plans, to include such health plans as an entity entitled
to release from liability and to otherwise generally apply the terms of this authorization and release to such delegated credentialing activity.
I understand and agree that this Authorization and Release is irrevocable for any period during which I am an applicant for Participation at the
Entity, or I am a member of Entity’s medical or health care staff, or a participating provider of the Entity. I agree to execute another consent if law
or regulation limits the application of this irrevocable authorization. Failure to promptly provide another consent may be grounds for termination or
discipline of the Participant by the Entity in accordance with the applicable bylaws, rules and regulations, and requirements of the Entity.
I acknowledge that the investigation of information in this Application and the release and exchange of Disciplinary Inform ation by the Entity and
its Agents are done to achieve, maintain and improve quality patient care.
All information provided by me in the Application is true to the best of my knowledge and belief. I understand and agree that any material
misstatement in or omission from the Application may constitute grounds for denial or revocation of Participation. I understand and acknowledge
that the Entity shall be solely responsible for all decisions concerning the granting of Participation.
I further acknowledge that I have read and understand the foregoing Authorization and Release. A photocopy of this Authorization and Release
shall be as effective as the original.
Signature________________________________________________________________
Revised 9/08
Date_______________________
IMMUNIZATION DOCUMENTATION FORM
Type of Credentialing Application: INITIAL
NOTE: Completion of this form is not required if you are ONLY applying to Behavioral Healthcare Providers (BHP), Fairview Physician
Associates (FPA) or Crosstown Surgery Center (CSC). The form must be submitted if you want to work at any Fairview hospital or
clinic.
Title
Practitioner Name
(please print)
Last 4 Digits of Social Security Number
Preferred Email Address
Preferred Phone Number
Complete and fax this form (or scan & email to [email protected]) with required documentation within one week to
Fairview’s Employee Occupational Health Services Department (EOHS). Please use the attached fax cover sheet.
EOHS staff will review your immunization history as well as all documentation you submit. EOHS will determine whether you
currently meet requirements and, if not, provide options for obtaining the required vaccinat ions or titers. Practitioners are
responsible for the costs associated with meeting the requirements. Fairview employed practitioners may receive
services at no charge from your EOHS site(s). EOHS staff will inform the Fairview System Credentialing Office and Fairview
entity Medical Staff Office when you have met the requirements.
Satisfactory documentation and compliance is required BEFORE your initial appointment application will be approved at the
Fairview entity(ies). To meet the immunization requirements, it may take a minimum of 4 weeks if vaccination(s) are required.
INSTRUCTIONS: Check the appropriate statement for each immunization and sign/date this form.
Fax this form and required documentation to EOHS using the attached fax cover sheet.
Immunization
Tuberculin
Skin Test
(TST)
Measles,
Mumps and
Rubella (MMR)
& Varicella
Hepatitis B
Requirements
Two step Mantoux test (negative TST from last
12 months will count as first step, second step
within past 90 days OR negative TST two
consecutive years, one within the last 12
months). QuantiFERON - TB Gold Test may be
substituted in lieu of skin test.
If positive, CXR required or documentation of
CXR in past 5 years and complete symptom
questionnaire
Documentation of 2 live virus vaccines; or
Documentation of disease by a healthcare
provider; or
Documentation of positive titers
(Note: Verbal history of disease is not an
acceptable form of documentation)
Documentation of completed series; or
Declination signed; or
Positive titer
Required Documentation - Please complete
appropriate statement
____I have attached documentation of my most recent
Mantoux test (within last 12 months); or
____If past positive Mantoux - I have attached
documentation of most recent CXR; or
____I do not have any of the above
____I have attached documentation of 2 live virus
vaccines for MMR and Varicella; or
____I have attached documentation of diseases by a
healthcare provider; or
____I have attached documentation of positive; or
____I do not have any of the above
____I have attached documentation of completed series;
or
____I have signed the attached declination form; or
____I have attached documentation of positive titer
*For questions or concerns – please contact Theresa Layon with EOHS
at (612) 672-4602 or email [email protected]
Signature _________________________________________ Date ________________
FAX COVER SHEET
Immunization Documentation
Fax To
Fairview Employee Occupational Health Services (EOHS)
Attention: Theresa Layon
Fax Number
~All Fairview Entities is (612)-273-4723
Sender’s Name: _____________________________________________
Sender’s Phone Number: ______________________________________
Documentation attached to this fax cover sheet:
~Completed, signed & dated Immunization Document Form
~Documentation of required immunizations
For questions or concerns; please contact Theresa Layon with EOHS
at (612) 672-4602 or email [email protected]
EOHS Policy
Employee Occupational Health Services
Attachment A
Hepatitis B Questionnaire/Declination
(Please write legibly)
Name _______________________________________SS#_____________________________
Department ________________________________ Job Title ____________________________
_______ 1) I have received Hepatitis B vaccine in the past.
, ________)
□series of three completed (dates given
,
□series incomplete, number of shots given ________ (year)
Hepatitis B titer results
□unknown / not previously drawn
□not immune
□known immune (date of positive titer
___________ )
_______ 2) I have not received Hepatitis B vaccine in the past. I have been offered the Hepatitis B
vaccination recommended for my job description.
□ I would like to receive the Hepatitis B vaccine. I will contact Employee
Occupational
Health Services at 612-672-5050 to schedule the vaccination series. I understand that the
vaccination series will be 3 doses and that it is my responsibility to complete the entire series, or
contact Employee Occupational Health Services to sign a declination. Failure to respond to an
EOHS reminder letter within 2 weeks of letter date will serve as my declination.
Signature_____________________________________Date___________________________
_______3) □ I do not wish to receive the Hepatitis B vaccine at this time.
(Please sign declination below)
DECLINATION
(OSHA 1910.1030, App A)
I understand that due to my occupational exposure to blood or other potentially infectious materials I may
be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be
vaccinated with Hepatitis vaccine, at no charge to Fairview employees. However, I decline Hepatitis B
vaccination at this time. I understand by declining this vaccine I continue to be at risk of acquiring
Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other
potentially infectious materials, and I want to be vaccinated with Hepatitis B vaccine, I can complete the
vaccination series at no charge to Fairview employees.
Signature _____________________________________ Date ___________________________
Immunization Requirements for Membership on Medical or Allied Health Staff
Frequently Asked Questions
1.
Why is Fairview implementing an immunization policy?
Healthcare practitioners are at a higher risk for exposure to and possible transmission of vaccine-preventable
diseases. It is imperative that health care practitioners protect patients from risk of disease. Ensuring those who
come into contact with patients in Fairview entities are protected from preventable diseases is an important part of
providing safe, exceptional care.
2.
Who must comply with the new immunization requirements?
Initial Applicants - Practitioners submitting initial applications received by the Fairview System Credentialing Office
after February 1, 2009 must meet the requirements.
Practitioners Currently on Staff at Fairview - All practitioners currently on staff will be required to meet the
requirements over a two year time period as they are reappointed according to Fairview’s reappointment schedule.
3.
How did Fairview determine which immunizations and what documentation is required?
The policy is based on recommendations from the CDC, MMWR, and ACIP. Immunization recommendations are
more rigorous for health care workers than the general public. For example, the birth date of 1957 may be sufficient
for immunity requirements for the general public but is not currently what is recommended for health care
professionals. Additional information regarding the CDC, MMWR and ACIP recommendations is enclosed.
4.
What is the process for providing the required immunization documentation?
Practitioners will receive instructions from the Fairview System Credentialing Office at initial appointment and
reappointment. Practitioners will be responsible for contacting Fairview’s Employee Occupational Health Services
(EOHS) to initiate the process. EOHS contact information will be included in the instructions.
EOHS staff will review your immunization history as well as all documentation you submit. EOHS will determine
whether you currently meet requirements and, if not, provide options for obtaining the required vaccinations or titers.
Practitioners are responsible for the costs associated with meeting the requirements.
5.
Can I submit my immunization documentation before my reappointment time?
Yes. EOHS staff will enter your immunization history into the database upon receipt. When you receive the
immunization forms with your reappointment application packet, you may notify EOHS that your history was
previously submitted. EOHS will then advise you if any additional immunizations or testing is needed.
6.
What will you do with my immunization record?
EOHS will maintain your immunization records and adhere to applicable privacy requirements. Once you have
satisfied Fairview’s requirements, you may contact EOHS and request a copy of your records at any time.
7.
What if I fail to provide the required documentation during my initial application or reappointment?
Satisfactory documentation of compliance is required prior to final approval of initial application or reappointment.
Revised 2/20/2009
Initial Application Process Flow Chart
There are two parts to the credentialing process:
1) credentials verification performed by Fairview System Credentialing Office; and
2) review and approval of verified application by Medical Staff at individual Fairview entity(ies)
Credentialing application received by
Fairview System Credentialing Office
(FSCO)
Is
application
complete?
PART 1:
RESPONSIBILITY
OF FAIRVIEW
SYSTEM
CREDENTIALING
OFFICE
Part 1 avg. 40 days
(turnaround time
dependant on delays
encountered)
No
Incomplete
application returned
to applicant
Delay in
process
Yes
Application reviewed, verification letters faxed/emailed to
sources, verification of license/insurance/DEA/board
certification completed, letter sent to applicant if clarifying
information needed
Verifications from sources obtained and reviewed for
discrepancies, privilege requests and supporting
documentation reviewed, additional information from
applicant or sources obtained if necessary, ensures all
information received and file complete
Final review of file performed and verified application sent
to Medical Staff Office at appropriate Fairview entity(ies)
Delay in process if
sources don't respond,
discrepancies identified,
or additional information
needed from applicant or
sources
Application closed as
incomplete if information
unable to be obtained from
sources or applicant
Application and supporting documentation reviewed by
Medical Staff Office personnel, additional information
requested if necessary, Department Chair/Credentials
Reviewer contacted to review file
PART 2:
RESPONSIBILITY
OF INDIVIDUAL
FAIRVIEW ENTITY
Part 2 avg. 30 days
(turnaround time
dependant on entity
process and delays
encountered)
File reviewed by Department Chair/Credentials Reviewer,
additional information requested if necessary,
recommendation to approve or deny
Department Chair/Credentials Reviewer recommendation
reviewed by Credentials Committee and/or Medical
Executive Committee, recommendation to approve or deny
Delay in process if
entity requests
additional information
from applicant or
sources
Decision to approve or deny applicant's membership and
privileges by Board of Directors individual Fairview
entity(ies)
Applicant and System Credentialing Office notified of
Board's decision by Medical Staff Office
SYSTEM CREDENTIALING AND FAIRVIEW ENTITY PHONE NUMBERS ON REVERSE
visio\Initial App Flow Chart2.vsd
Revised 1/2010
Fairview System Credentialing Office
Initial Application Staff
Initials Phone:
Initials Fax:
Initials Email:
612-672-7700 Press option 1
612-672-4123
Nicole Acord
651-917-1441
[email protected] update applications
Jay Botthurath
Megan DeDomines
Dao Khang
Dianne McCabe
Andrea Norles
612-672-7591
612-672-7594
651-917-1425
612-672-4352
612-672-4172
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Fairview Entity
Medical Staff Office Personnel
Fairview Medical Group (Clinics)
Tracy Kraemer 763-392-5644 [email protected]
Fairview Lakes Medical Center
Linda Wahman 651-982-7432
[email protected]
Fairview Maple Grove Ambulatory Surgery Center
Denise Holmquist 763-898-1400 [email protected]
Fairview Northland Medical Center
Michelle Jaskolka 763-389-6517 [email protected]
Fairview Ridges Hospital
Michelle Toranza 952-892-2103
Fairview Southdale Hospital
Jennifer Lutz
952-924-1478
Acacia Perkins
952-924-5770
[email protected]
[email protected]
[email protected]
University of Minnesota Medical Center, Fairview &
University of Minnesota Amplatz Children’s Hospital
Laura Nelson
612-273-1945
[email protected]
Fairview Health Services
PRIVILEGING PRINCIPLES
The credentialing and privileging process exists to determine the competency of persons providing care to
Fairview patients. An important and primary goal of the process is to serve Fairview patients.
Everyone who provides care to Fairview patients should be able to demonstrate competency to provide the
care.
There may be more than one way to demonstrate competence.
Competency determinations are ongoing for each person.
While training may be the initial evidence of competence, the initial training may or may not be sufficient
to demonstrate competence going forward and demonstration of ongoing training and experience may be
necessary.
Particular privileges are not necessarily specialty specific. Instead they are competency specific.
Privilege requirements evolve over time.
The Fairview entity, not the credentialing and privileging process determines the specific services to be
provided at the entity.
In certain circumstances related to the orderly operation of the facility and/or the enhancement of patient
care, the facility may limit specific privileges to specifically identified persons. (Exclusive contracts, etc.).
Approaches to determining competency should be consistent across Fairview.
Approved by System Credentialing Policy Committee on January 30, 2007
Fairview System Credentialing Office
Initial applications require a $200 application fee.
Applications will not be processed in the Fairview System Credentialing Office until payment is received.
There are two payment options:

Check: Please make the check payable to Fairview System Credentialing and include it in your Initial
Application or mail to:
Fairview System Credentialing
2344 Energy Park Dr Ste 127
St. Paul, MN 55108
**Please note: If multiple initial applications are included in one combined check submission, all
applications tied to the fee must be received and complete in order to begin processing them.

Credit Card: Please complete the information below and mail with the initial application. This
information will be shredded once processed for payment.
Credit Cards accepted are: Discover, Mastercard and Visa.
First name
Middle Initial
Last Name
Applicant Name
(if different from card holder name)
Business Name(if applicable)
Street Address
City
State
Signature
Zip
Date
Card Type (circle one)
Discover
Card Expiration Date
/
Mastercard
(Month/Year)
Visa
Payment Amount
Credit Card Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Security code _ _ _
Applications will not be processed in the Fairview System Credentialing Office until payment is received.
By application or reapplication to the medical staff or allied health staff of Fairview Health Services, I agree to abide by
the Code of Professional Behavior
Fairview Health Services
Medical Staff and Allied Health Staff
Code of Professional Behavior
Fairview’s Vision
Our passion for excellence for our patients drives us, in partnership with the University of Minnesota, to be the
best health care delivery system in America.
To this end, we the medical staff and allied health staff of Fairview Health Services, acknowledge the guiding
code for our profession and commit to:
Place the patient at the center of all we do
Apply the best science we know
Model the highest level of professionalism
Actively engage as a collaborative member of the care team
Be aware of, and comply with the rules
Endorsed by System Credentialing Policy Committee 1/29/2008
I.
Place the patient at the center of all we do
1. I am readily available and approachable
2. I discuss medical conditions and medically appropriate treatment choices available with patient
3. I advocate for the patient
4. I collaborate with other members of the care team to coordinate care.
5. I respect patient confidentiality
6. I respect patient diversity
7. I encourage questions and respond to them openly
8. I respect the important role of family and friends
9. I will do my best to meet patient needs within the constraints of science, ethics and available
resources.
II.
Apply the best science we know
1. I maintain professional knowledge by attending continuing education, reading and learning from
colleagues
2. I avoid treatment and procedures that are not in keeping with the latest science
3. I consult with experts in all professions and I don’t provide care outside my area of expertise
4. I acknowledge by my actions and words that I am an educator for patients, family and colleagues and
I have a duty to apply the best possible science to that role.
5. I disclose real or potential conflicts of interest that may create the perception of bias.
III.
Model the highest level of professionalism
1. I share information and knowledge proactively with other members of the care team
2. I communicate effectively with colleagues and avoid rude behavior
3. I maintain a respectful manner
4. I challenge the professional judgment of others in a polite manner and I do not speak negatively of
other health providers to patients and families
5. I model appearance and deportment in a way that provides confidence and comfort to the patients.
6. I will refrain from sexual contact or romantic relationships with a current patient.
7. I refrain from conduct and activities that may impair professional judgment and ability to act
competently
IV.
Actively engage as a collaborative member of the care team
1. I actively participate in team conversations, meetings and rounds related to care
2. I am willing to actively engage in medical staff committees
3. I am willing to share helpful information
4. I listen to others
5. I communicate effectively with referring physicians
6. I respond to colleagues and staff in a timely manner
7. I manage hand-offs well
V.
Be aware of and comply with the rules
1. I have an obligation to follow pertinent Fairview policies
2. I help create and sustain standards of care delivery
3. I monitor my own behavior and the behavior of others
4. I provide honest feedback and coaching to others when needed