Kathy Matzka, CPMSM, CPCS

Writer/Speaker/Consultant

Inquiries

Kathy Matzka, CPMSM, CPCS
1304 Scott Troy Road
Lebanon, IL 62254
kathymatzka@kathymatzka.com
Phone (618) 624-8124
Fax (618) 624-8124

FORMS AND DATA COLLECTION TOOLS DEVELOPMENT

Need help with developing policies, procedures, credentialing letters, or privileging forms? Kathy will work with you and your medical staff officers in developing the right credentialing privileging tools for your medical staff. 

Many medical practices strive to provide patients with comfortable, professional facilities, but then lose that professional appearance by giving patients forms to complete that have been copied so many times that they can barely be read. Kathy can help you design efficient, attractive, user friendly, forms in a format that works for your office – WordPerfect, Microsoft Word, or PDF. Get the paper form, plus the electronic file so that you can do future updates yourself and save money! See how much updating those tired, old forms will add to your office’s professional appearance!

 

SAMPLE FORMS AND DOCUMENTS

Description File
Sample Bylaws Language for Temporary Privileges Under TJC CAMH Standards.  This language can be used to update bylaws to comply with The Joint Commission's medical staff standards for granting temporary privileges. Bylaws Language (20KB)
Sample Human Resources Policy for Students Participating in Medical Training. Human Resources Student Policy (20.5KB)
Sample Policy and Process for Credentialing and Privileging of Non-independent APRN and PA Practitioners through the Human Resources Department (use only for those not making independent patient diagnosis or care decisions) Credentialing and Privileging Non_LIP.doc (36KB)
Sample Form for Requesting Primary Source Verification From Hospitals.  This form incorporates an evaluation based on the ACGME's Core Competencies. Sample Hospital Reference Letter (75.5KB)
Sample Peer Recommendation Letter. This form incorporates an evaluation based on the ACGME's Core Competencies. Peer Reference Letter (73.0KB)
Credentials File Audit Form for Compliance with Joint Commission Medical Staff Standards for Credentialing and Privileging.  This can be used by hospitals to evaluate their own compliance with standards or to audit contractual services under TJC standards. Chart Audit Form (120KB)
Credentials Committee Orientation PowerPoint Presentation.  Customize this presentation for use in orienting your credentials committee members to your facility's credentialing and privileging processes. Credentials Committee Orientation PowerPoint Presentation (72.5KB)
Letter and Chart for Documentation of Compliance with Joint Commission Medical Staff Standards for Contract Services Providers. Use this letter and form to ask contracted service providers to document compliance with The Joint Commission's Medical Staff Standards for Credentialing and Privileging Chart for Documentation of Compliance with Joint Commission Medical Staff Standards for Contract Services
Structured Interview Form.  Use to standardize the interview process for new applicants. Structured Interview Form
Telephone Interview Form for Affiliation.  Use to document telephone verifications for medical staff applicants. Telephone Interview Form - Hospital
Telephone Interview Form for Peer Recommendatino.  Use to document telephone/verbal peer recommendations. Telephone Interview Form - Peer
FPPE Evaluation Plan. Use for documenting Focused Professional Practice Evaluation FPPE Evaluation Plan
Worksheet for Consideration of a New Privilege.  Use to document issues to be determined when a new procedure is requested that the organization has not yet provided. Worksheet for Consideration of New Privilege