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Credentialing and Privileging - Verifying Practitioner Identification

What are the requirements for verifying practitioner identification?

Any examples are for illustrative purposes only.

The Joint Commission requires that organizations verify the identity of the applicant 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 may be done at any point during the application process or when the applicant enters the organization.
Examples may include:
  • 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
  • Use of a telecommunications link that includes both audio and video capabilities
If identification confirmation occurs on-site, organizations consisting of multiple settings, 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, 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. 

If the applicant provides only a copy of the photo ID, or a notarized document indicating the identity was verified by another entity, it would not satisfy the requirement for verification. 

For telehealth service providers only:
Applicant identity verification may be completed offsite at the distant (provider) location, as the practitioner never comes onsite where the patient is located.  The organization determines the process for verifying practitioner identity.

Last updated on November 12, 2020
Manual: Critical Access Hospital
Chapter: Medical Staff MS

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