Privacy Act Statement

							                                           BUMEDINST 6320.66E
                                           29 Aug 2006

                           APPENDIX I

          PRIVACY ACT STATEMENT INDIVIDUAL CREDENTIALS
          FILE (ICF)/INDIVIDUAL PROFESSIONAL FILE (IPF)

1. Authority: The authority for collection of information
including social security number (SSN) is found in Section 301,
Title 5, United State Code.

2. Principal purpose for which information is intended to be
used: This form provides the advice required by the Privacy Act
of 1974. The personal information will facilitate and document
your credentials. The SSN of the member is required to identify
and retrieve credentials and professional files.

3. Routine uses: The primary use of this information is to
provide, plan and coordinate members credentials and privileging
information. This will aid the privileging authority to review
the member's academic qualifications, make a determination on the
member's clinical competence and grant appropriate privileges
requested.

4. State whether the disclosure is mandatory or voluntary and
the effect on the individual of not providing information.

     a. For all personnel, the requested information is
mandatory because of the need to document all credentials,
privileging and quality assurance (quality management) data.

     b. If the requested information is not furnished,
establishment of eligibility for appointment to the medical staff
and granting of privileges will not be possible.

     c. This all inclusive privacy act statement applies to all
requests for personal information made by personnel for
credentials verification purposes and shall become a permanent
part of your ICF or IPF.

     d. This PAS covers the necessary data collected by the
individual departments to complete the performance appraisal
report (PARs) and clinical appraisal reports (CARs).



   Member Signature   ________________________________________

   Member SSN         ________________________________________

   Date               ________________________________________