Guide
Credentialing volunteer clinicians at a free clinic
Credentialing a volunteer clinician means confirming their license, education and training, identity and ability to do the job, then privileging them for a defined scope of care. Clinics sponsoring volunteers under HRSA’s Free Clinics FTCA program apply for deeming each year and re-credential on a regular cycle.
What does credentialing a volunteer clinician involve?
Confirming that the clinician is licensed, trained, who they say they are and fit to practice, checking the most important items at the source, and keeping a dated record of every check.
HRSA lists a credentialing and privileging system among the requirements for its Free Clinics FTCA program, which extends federal malpractice protection to deemed clinics’ volunteers and staff. The same pattern is sound practice for a clinic that isn’t deemed. Americares’ FTCA guide for free clinics splits the work in two: license, education and training are verified at the primary source, while identity, vaccination records and CPR certification can come from secondary sources such as documents the clinician provides.
| Element | What you confirm | How it’s usually verified |
|---|---|---|
| License or certification | Active, unrestricted and valid in your state | Primary source: the state licensing board’s lookup (or Nursys for nurses) |
| Education and training | Degree, residency or certification for the role | Primary source, or a credentials verification organization |
| Malpractice history and disciplinary actions | Payments and actions on record | National Practitioner Data Bank (NPDB) query |
| Identity | Government-issued photo ID | Copy on file (secondary source) |
| Immunizations and TB screening | What your clinic policy requires | Documents from the clinician (secondary source) |
| BLS or CPR | A current card | Copy on file (secondary source) |
| DEA registration | Only for clinicians who prescribe controlled substances at the clinic | Copy on file, with its expiration date |
| Exclusion lists | Not excluded from federal health care programs | OIG LEIE and SAM.gov searches, saved with the date |
A clinic in the FTCA program may delegate credentialing to a credentials verification organization (CVO), often a partner hospital, under a written agreement. The hospital’s checks count only if they fall within HRSA’s time frames.
What’s the difference between credentialing and privileging?
Credentialing confirms who a clinician is and what they’re qualified to do. Privileging is your clinic’s decision about what they may do at your clinic, granted by the board or the medical director it delegates to.
A retired family physician may be fully credentialed and still be privileged only for adult primary care visits, not procedures. Americares describes three ways clinics grant privileges: verifying the same privileges at another health care institution, having another deemed practitioner observe the clinician, or training them in the specialty. Peer review then informs each renewal. Write each clinician’s privileges down, with the date and the name of whoever approved them.
How often do free clinics re-credential?
Commonly every two years, with a fresh NPDB query each time. FTCA deeming itself is renewed every calendar year. Confirm the current cycle in HRSA’s Free Clinics FTCA program guidance before you set your policy.
- Re-credentialing and re-privileging. Americares’ guide describes HRSA’s time frame as reviewing credentials and privileges every two years, and screening deemed health professionals through the NPDB every two years.
- Annual deeming. The clinic reapplies each year and lists everyone who needs coverage for the next year. Nobody rolls over automatically, and coverage isn’t retroactive to before the approval date.
- Between cycles. Licenses, BLS cards and DEA registrations expire on their own dates. Track them continuously, as described in how to track volunteer credentials and expirations, rather than waiting for the two-year review.
Which exclusion lists should you check?
At minimum, the HHS Office of Inspector General’s List of Excluded Individuals/Entities (LEIE), plus SAM.gov if your clinic receives federal funds. Check when someone joins and again on a schedule, because the LEIE changes every month.
- OIG LEIE. The people and entities excluded from federally funded health care programs. OIG publishes monthly files of additions and reinstatements and tells health care entities to check the list routinely, for new hires and current staff. A free clinic that bills no federal program faces less payment risk, but a match is still a serious red flag.
- SAM.gov exclusions. The federal government’s list of people and organizations barred from federal contracts and grants. It matters most if you receive federal grant money.
- Your state’s Medicaid exclusion list, if your state publishes one.
- NPDB. Not an exclusion list, but it shows malpractice payments and adverse actions. FTCA clinics query it at credentialing and every two years.
Save a dated screenshot or PDF of each search and its result, so you can show the check was done and when.
Do state laws add requirements?
Yes. States decide who may practice, and several have special rules for volunteer clinicians. Three examples show how much they differ.
- Arizona. A.R.S. § 32-3217 lets a state health board give a professional licensed in another state a volunteer health services registration to practice at a free medical clinic for up to 14 days each calendar year. Among other conditions, the license must be active and unrestricted, never revoked or suspended, with no unresolved complaint.
- Ohio. Ohio Rev. Code § 4731.295 offers a volunteer’s certificate to retired physicians with at least ten years of licensed practice. Holders may treat only indigent and uninsured people, take no pay, and renew every three years with continuing medical education.
- South Carolina. S.C. Code § 38-79-30 shields licensed providers who volunteer without pay from civil liability except for gross negligence or willful misconduct, and says the agreement to provide free, non-emergency care must be in writing. Read the current text before relying on it.
Ask your state licensing boards and your state’s free clinic association what applies where you are.
What goes on a credentialing checklist?
Thirteen items take a new volunteer clinician from application to their first patient. Print it, or copy it into your own file.
- Application received License numbers, education, work history, references and malpractice history.
- License verified with the state board Save the lookup result with its date.
- Education and training verified Or board certification, at the primary source or through a CVO.
- NPDB query run Record the result and the query date.
- OIG LEIE and SAM.gov searched Save each result with its date.
- Government photo ID on file
- BLS or CPR card on file Plus DEA registration if they prescribe controlled substances.
- Immunizations and TB screening on file As your clinic policy requires.
- Agreements signed Volunteer agreement, confidentiality and any state-required provider agreement.
- Malpractice coverage confirmed FTCA deeming, the clinic’s policy or the clinician’s own.
- Privileges approved By the medical director or board, with the scope written down.
- Orientation and HIPAA privacy training done
- Next re-credentialing date set With reminders for every item that expires before then.
How can software help?
Software can’t verify a license for you, but it can make sure every check happens, is recorded with a date and comes around again on time.
Nehemiah isn’t a credentials verification organization and doesn’t query the NPDB for you; it tracks that your team did, and when. See how compliance tracking works.
Questions people ask
Do free clinics have to credential volunteer clinicians?
Clinics deemed under HRSA’s Free Clinics FTCA program must have a board-approved credentialing and privileging process. Clinics outside the program aren’t bound by FTCA rules, but credentialing is how any clinic shows it checked who is treating patients, and your malpractice carrier may require it.
Does FTCA cover every volunteer at a deemed clinic automatically?
No. Per Americares’ FTCA guide, the clinic applies, lists each person it wants deemed, and reapplies every year; nobody rolls over to the next year automatically, and coverage starts on the approval date, not before. Confirm the current rules with HRSA.
Can a clinician licensed in another state volunteer at our clinic?
Only if your state allows it. Some states have volunteer exceptions, such as Arizona’s volunteer health services registration for up to 14 days a year at a free medical clinic. Check with your state licensing board before the first shift.
Can a retired physician volunteer?
Often, under a state volunteer or retired-practitioner license. Ohio’s volunteer’s certificate is one example: retired physicians may treat indigent and uninsured people without pay. Rules differ by state, so check with your licensing board.
What is a credentials verification organization (CVO)?
An organization that verifies credentials on a clinic’s behalf. A free clinic in the FTCA program may delegate credentialing to one, often a partner hospital, under a written agreement.