Credentialing and Privileging - Verifying Practitioner Identification

What are the requirements for verifying practitioner identification?

The Joint Commission requires that organizations verify the identity of the individual seeking privileges by viewing one of the following:
  • A current picture organizational ID card
  • A valid picture ID issued by a state or federal agency (for example, a driver’s license or passport)
The verification is required to be conducted onsite at the organization, except for telemedicine/tele-interpretive service providers where the verification may be completed offsite at the distant location.  The verification may be done at any point that the applicant enters the organization, For example:
  • To pick up the application
  • For an interview by the department chair
  • When arriving to first provide services
  • When having their photo ID badge picture taken
For organizations consisting of multiple settings, the verification may be conducted in any setting that falls under the scope of the accreditation survey. Once the verification has been made, a notation should be entered into the credentials file, such as on the documents checklist, etc.  If the verification is performed at a remote location from the main hospital, then the confirmation of the verification should be forwarded to the credentialing office for inclusion in the credentials file.

It is NOT required or recommended that a copy of the photo ID be taken or placed in the credentials files due to potential for identity theft.  Having only a copy of the photo, or a notarized document indicating the identity was verified by another entity would not satisfy the requirement for verification.  As noted, the only exception is for the telemedicine/tele-interpretive service providers.

See also EM.02.02.13 for details applicable to credentialing and privileging during disaster incidents.

Last updated on May 08, 2019
Manual: Behavioral Health
Chapter: Human Resources Management HRM

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