California Hospitals
Physician Acknowledgement

Background
Regulations at 42 CFR 412.46 (one of the conditions at 42 CFR 412, Subpart C) require hospitals to obtain only one signed acknowledgement from physicians who are being granted admitting privileges at a particular hospital. The physician must complete the acknowledgement at the time that he/she is granted admitting privileges at the hospital, or before or at the time the physician admits his/her first patient to the hospital. When the hospital submits a claim, it must have on file a signed and dated acknowledgement from the attending physician that the physician has received the notice specified in 42 CFR 412.46(b). Existing acknowledgements signed by physicians already on staff remain in effect as long as the physician has admitting privileges at the hospital.

Physician Acknowledgement Monitoring Report Template
Click the link below to download the electronic report template for submission of your list of all new physicians with admitting privileges.

Physician Acknowledgement Monitoring Report Template

Instructions:
Download the template to your computer and rename the file. Once completed, e-mail the template to
physician-acknowledgement-CA@hsag.com.