What is credentialing?

Credentialing is the process of assessing and validating a physician’s qualifications.

Why is credentialing important?

Hospitals credential physicians to protect the public from incompetent practitioners, minimize legal risk and meet regulatory requirements. Our goal is to provide the kind of quality health care we would want for ourselves and our families. The Ascension board of directors is ultimately responsible and liable for the practitioners they credential, and must go through the proper process to protect care providers from unfair practices.

The Credentialing Process at Ascension

Physicians receive an application packet, which includes:
  • application form
  • privilege delineation form to request the procedures they would like to be able to provide
  • copy of the Ascension Medical Staff Bylaws
  • cover letter requesting the following documents:
    • current Wisconsin license
    • DEA (if applicable)
    • CME and certifications
    • evidence of malpractice insurance coverage
    • health information
    • current photo
    • other documentation as required
  • additional information as appropriate.

Screening and Verification

Ascension screens each completed application for gaps in time frame, completeness, etc. Then we begin to verify all the information, including degree(s), internship(s), fellowship(s), license(s) in all states, medical malpractice history report for the past 10 years and board certification (if applicable). We make electronic queries to the National Practitioner Data Bank, the Licensing Board(s), OIG for Medicare/Medicaid Sanctions, AMA for physician profile and other sites (UPIN, Google, FSMB, Wisconsin Circuit Courts, Sex Offender Registry).

When Everything Is Complete

The Medical Staff Coordinator (MSC) screens the application and flags any gaps in service, liability cases or inconsistencies. We review references, and then take the application documentation to the department chair for review.

Credentials Committee

The Credentials Committee reviews the application and the department chair’s recommendation, then makes a recommendation to Medical Executive Committee for approval or further review. The Medical Executive Committee reviews the application and makes a recommendation to the board of directors.

The Board of Directors

The board of directors reviews the information from the Medical Executive Committee. The president of the medical staff and the board of directors representative are usually present to discuss and answer any questions. The board of directors either grants final approval of the application, requests more information or denies the application.


If approved, the medical staff coordinator (MSC) will assure all signatures are in place and announce the approval via e-mail.
  • Hospital and clinic personnel may view privileges on the intranet.
  • All pertinent rosters will include applicant.
  • Applicant receives a dictation number and entry into the Meditech system.
  • MSC forwards a letter to the applicant from the medical staff president, welcoming him/her and informing him/her of the granted provisional status and privileges.
  • MSC arranges an orientation to the hospital.

What if it’s not approved?

  • We may need more documentation from the applicant.
  • Practitioner may appeal via the fair hearing process.

Training for Medical Staff Coordinators

  • Wisconsin Association of Medical Staff Services (WAMSS)
  • National Association of Medical Staff Services (NAMSS)
  • Certified Provider Credentialing Specialist
  • Certified Professional Medical Services Management


For more information about credentialing, please contact Mary Lehr, Medical Staff Coordinator, at (920) 223-2067.

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1506 S. Oneida St
Appleton, WI 54915
(920) 738-2000

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