Enclosure (4) to COMDTINST 6010.2B
PRIVACY ACT STATEMENT FOR
INDIVIDUAL CREDENTIALS FILE (ICF) REQUESTS
1.
The authority for collection of information including social security number (SSN) is found
in the Privacy Act of 1974, 5 U.S.C. 552a.
2.
Principle 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 our verification of your credentials. The SSN and date of birth for the
member is required to identify and retrieve credentials verification documents.
3.
Routine Uses:
The primary use of this information is to provide, plan, and coordinate member's credentials and
privileging information. This will aid the privileging authority to review the member's academic
qualifications, make a determination of the member's clinical competence, and grant appropriate
privileges requested.
4.
Whether disclosure is mandatory or voluntary, and effect on individual of not providing
information:
For all personnel, the requested information is mandatory because of the need to document all
credentials and privileging data. If the requested information is not furnished, establishment of
eligibility and granting of privileges will not be possible. 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.
5. Your signature acknowledges that you have been advised of the foregoing, that you authorize
release of information from entities that can assist in verification of your credentials, including
facilities where the applicant may currently hold privileges, individuals, and organizations that
provide information concerning the applicant's participation in Coast Guard health care activities,
allowing for primary source verifications, and that you hold the United States Coast Guard, the USCG
Auxiliary, and any authorized individuals involved in the credentialing process and all individuals
and organizations who provide information harmless as long as they are acting in good faith and
without malice for actions taken during the credentials verification and privileging process.
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Signature
Date
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Printed Name
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