Requirements for Urgent Care Credentialing

Applicant Name*

First Last

Specialty*

Board Certification*

Board Certification *

Yes
No

Certification (Current)*

ACLS
PALS/APLS

All practitioners requesting network participation must meet Neighborhood’s credentialing criteria (available upon request). Practitioners practicing at urgent care settings (MD, DO, NP and PA) must be able to treat children and adults and should have completed training¹ in emergency medicine, family medicine and/or internal medicine/pediatrics (Med/Ped). Practitioners who have not completed training in one of the specialties noted above are required to attest to the following competencies and submit for evaluation as part of the credentialing process.

Review the following urgent care competencies and attest to them by signing below:

Cardiac: Bradycardia; Chest Pain /myocardial infarction; Cyanotic Heart Disease;
GYN: STD/PID; Dysfunctional Uterine Bleeding; Evaluation Protocol of Rape/Domestic Abuse; Torsion of Ovarian Cyst;
Neurological: Headache; Head Trauma; Seizures (Febrile and other); Stroke or Transient ischemic attach (TIA);
Pediatrics: Abuse, Airway obstructions, Asthma, Bronchiolitis, Croup, Dehydration, Febrile Infant; Intussusception, Pertussis, Sepsis;
Pregnancy: Diagnosis of Pregnancy; Bleeding in Pregnancy; Ectopic Pregnancy;
Respiratory: Airway Obstruction; Asthma / Wheezing; COPD; Embolic Phenomena; Epiglottitis; Foreign Body Aspiration Pulmonary Embolism; Shortness of Breath; Stridor;
OtherAbdominal Pain, Appendicitis, Anaphylaxis, Burns, Diabetic Ketoacidosis, Dehydration, Fractures, Drug/ETOH Overdose, Hypothermia, Infectious Diseases (tick-borne disease, meningitis, sepsis, etc.), Behavioral Health Emergencies, Mental Status Changes, abuse-dependence, Sepsis, Shock, Sickle Cell Disease, Significant Lacerations.

Please describe process for addressing the needs of clients who arrive at your center with issues such as substance abuse and dependencies; pregnancy-related issue; pediatric emergency and/or seriously ill child:*

I have read and attest that I have the skills, knowledge and experience to recognize, manage and triage urgent/emergent conditions in adult and pediatric patients including but not limited to competencies listed above.

Applicant Signature*

Date*

Supervising Physician Print Name*

First Last

Signature*

Date*

Medical Director Print Name*

First Last

Signature*

Date*

Footnote 1: Physicians must have completed residency training / nurse practitioners must have certification in population foci area noted

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