Published August 25, 2014
Mrs. Monica Bilecky, credential manager, verifies credential files at David Grant USAF Medical Center. (U.S. Air Force photo/ Staff Sgt. Liliana Moreno)
Credentialing and Privileging Checklist
Graduating Resident/New Provider (for explanation of forms, see below)
□ AF Form 494/475
□ Privilege List (completed by program director)
□ AF Form 1562 (1)
□ Interview w/SGH (scheduled?)
□ BLS and ACLS,PALS,NRP (if applicable)
□ AF Form 1540 (E-application completed, reviewed and e-signed
□ Privilege list--Electronically (Fully Competent /With Supervision or manual, if applicable, (completed by applicant according to directions using codes, 1, 2, or 4)
Joining us from another facility
Your PCF should have been forwarded to us from your previous MTF. Once your file is received, it is reviewed for completeness. An incomplete file, w/o (3) AF 1562's appropriately completed, an AF Form 22 and current in BLS, and ACLS, ATLS, PALS, NRP (if applicable), will cause a delay in processing. You must complete an application for privileges, a new privilege list and meet the same requirements as others applying for privileges. (Electronic E-app required when applicable) CaC card is required.
Civilian/IMA /USAFR /Volunteer
□ AF Form 1540
□ AF Form 1562/reference letters (3)
□ Interview w/SGH
□ All required documentation/license/certifications
□ Civilian Privilege List (Civilians/USAFR/IMA's)
□ SP 85 (Criminal History Backround Check-
(Civilians/Volunteers) if applicable.
□ Proof of Insurance (civilians, if applicable)
Before signing your application, please review it for completion. Please be sure all signatures, explanations, (if necessary) are complete and that all of the required documentation is included.