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Acknowledgement of Medical Staff Duties and Responsibilities

Thank you for viewing the discussion of medical staff duties and responsibilities presented by MyMichigan Health’s Credentialing and Privileging Committee.

Please complete and submit this form to confirm you understand the following requirements of medical staff membership:

Applicant Requirement Summary

  • Board Certification Requirements – If a provider has not already done so, the medical staff member must become board certified within five years from the date of completion of residency/graduation, and subsequent maintenance of certification.

  • Quality Initiatives (i.e. Core Measures, PCMH, BCBS) – MyMichigan Health participates in quality initiatives with several organizations and it is expected that the medical staff comply with the guidelines.

  • Medical Record Completion – The medical staff is expected to complete records in a timely manner, otherwise resulting in a progressive disciplinary process up to automatic resignation.

  • Committee Service – The medical staff is expected to participate in departmental and medical staff committees.

  • FPPE – Competency is initially assessed by Focused Professional Practice Evaluation with facility specific requirements (information to be provided). Primarily medical specialists are proctored for 10 retrospective cases. Primarily surgical/invasive specialists are proctored for five concurrent and five retrospective cases.

  • OPPE – Clinical competency will be assessed by Ongoing Professional Practice Evaluation.

  • MyMichigan Health has a Professionalism Policy (formally called a Code of Conduct Policy) – Doctors, Nurses, PAs, NPs, and ancillary staff are all expected to work together in a collegial manner in an atmosphere of mutual respect for the care and safety of the patient.

  • Confidentiality Agreement

Submitting this form is equivalent to providing your signature as acknowledgement of this information.

Congratulations on joining our team!

Personal Assistance

We're here to help you to navigate the privileging and credentialing process. Please contact us with your questions.

Medical Staff Services
MidMichigan Health
4000 Wellness Drive
Midland, Michigan 48670

(989) 488-5752

(989) 839-1970


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Monday - Friday