Hospital Ancillary Credentialing and Re-Credentialing

Last updated: 02/20/2008

List of Hospital Credentialing Expiration of Privileges (in alphabetical order)

Instructions

Accessing the credentialing forms

PDF: Open the application (Adobe Acrobat Reader required), print and use as a blank form to be completed by hand or typewriter. Type or print legibly in blue or black ink. Once the application is complete, you may photocopy and submit the original with a signed attestation to each privilege to which you wish to apply.

Word: Download the Word document and complete form - the text boxes will expand to allow completion. Once the application is complete, save it to a file so that you will have the convenience of ongoing use. Whenever you apply for a new privilege, just check to make sure the information is current, print out the completed application, sign a current attestation and submit the original with all required documents requested in the criteria related to your privilege.

Completing the forms

When completing the employment section, please only list healthcare related employment.
Complete each section thoroughly and truthfully, and complete all fields. If an item is not applicable, indicate N/A.
You are responsible for providing current information at all times and to update substantial changes throughout the credentialing period. Please remember that you must sign and date a new attestation page each time your form is submitted.
Modification to the wording and format of the form will invalidate the application.
Attach additional sheets where necessary. (Indicate clearly the applicant's name on each attachment.)
Be sure to include the appropriate signatures.
Your application for privileges cannot be processed without this form's completion in its entirety. Please remember that it is the applicant's ultimate responsibility to ensure that all information has been received.

Submitting the forms

Submit the following to Cabell Huntington Hospital:
1. Credentialing or Re-credentialing Form
2. CHH Addendum - Hospital Required Information
3. Additional required documents and/or items listed in CHH Addendum and criteria
Send the original, completed application and accompanying documentation to:
- Tammie Silva
  Administration
  Cabell Huntington Hospital
  1340 Hal Greer Boulevard
  Huntington, WV 25701
It will take approximately thirty to sixty days for approval. You will be notified.

Hospital Ancillary Credentialing Forms

Important: All non Cabell Huntington Hospital employees are required to take to the HIPAA and MEC tests (see below) and include their answer sheets when submitting the application. A passing score of 80% on each test is required to receive credit for the training.

HIPAA Training [ PDF - 143KB ]
HIPAA Training Test [ PDF - 12KB ]
MEC Training [ PDF - 2.4MB ]
MEC Training Test [ PDF - 75KB ]
Infection Control Training [ PDF - 4MB ]
Infection Control Test [ PDF - 344KB ]

Application/Reapplication

Application: PDF | Word
Reapplication: PDF | Word

Criteria Documents
Title	PDF
Arterial Puncture (ABG)	View document [ 41KB ]
Audiologist	View document [ 40KB ]
Autopsy Technician	View document [ 49KB ]
Clinical Instructor (Non-Contractual)	View document [ 42KB ]
Clinical Nurse Educator	View document [ 43KB ]
Dental Assistant	View document [ 43KB ]
Dental Hygienist	View document [ 44KB ]
Emergency Chest Tube Insertion	View document [ 41KB ]
Emergency Insertion LMA-Fastrach (Hospital Employees)	View document [ 48KB ]
Emergency Intubation (EI)	View document [ 65KB ]
Emergency Release of Pleural Air by Needle Aspiration	View document [ 41KB ]
FEES	View document [ 163KB ]
Hospice Nurse	View document [ 50KB ]
Intraosseous Infusion	View document [ 40KB ]
Massage Therapist	View document [ 77KB ]
Pain Management Clinician	View document [ 75KB ]
Peripherally Inserted Central Catheter	View document [ 41KB ]
Private First Assistant	View document [ 92KB ]
Private Scrub Nurse	View document [ 79KB ]
Professional Educator and Employees of Outside Agencies	View document [ 81KB ]
Prosthetist/Orthotist	View document [ 75KB ]
Research Assistant/Study Coordinator	View document [ 77KB ]
Social Workers/Counselors/Rehabilitation Counselors	View document [ 85KB ]
Speech Therapist	View document [ 76KB ]
Umbilical Artery Catheter/Umbilical Vein Catheter Insertion by NICU Nurse	View document [ 75KB ]