Privacy Act and burden notice
The authority under Title 38 chapters 73 and 74, how the information may be used and released, OMB Number 2900-0621 and an estimated burden of 1 hour. It says submission is voluntary.
10-0376a
Credentials Transfer Brief
- Agency
- VA
- Revision
- July 2005
- Fillable fields
- 83
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-0376a: Credentials Transfer Brief
VA Form 10-0376a is the U.S. Department of Veterans Affairs Credentials Transfer Brief, listed under VHA on VA's page. It summarizes a health care provider's credentials: education and training, ECFMG certificate, state medical licenses, certifications, clinical privileges and National Practitioner Data Base query dates, with a column showing whether each item was verified at the primary source.
The brief is signed by a Medical Staff Coordinator, who adds the providing facility's name and the coordinator's telephone and fax numbers. Its clinical summary is written to the medical center receiving it and states that the provider's credentialing file has been reviewed and verified as of a given date. It is a VA credentialing form completed by VA staff, not a form a Veteran files.
The Privacy Act notice says the information is collected primarily to determine qualifications and suitability for employment. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-0376a
Items 1 and 2: identity and training
Name, Social Security number, type of appointment and specialty, then education, internship, residency and fellowship rows with degree or specialty, institution, location, completion date and a Y or N for primary source verified.
Items 3 and 4: ECFMG and licenses
ECFMG certificate number, issue date and verification, then each state medical license with state, license type, license number, expiration date and primary source verification.
Items 5 to 9: certifications and privileges
State dangerous controlled substance (CDS) certification, specialty and subspecialty board certification, BCLS and ACLS certification, clinical privileges granted in a product service line with a copy attached, and the National Practitioner Data Base query dates.
Item 10: clinical summary
Fill in statements on the provider's health attestation, clinical competence as attested by the Service Chief, telehealth services and the review of the credentialing file as of a date, plus a remarks space.
Items 11 to 15: coordinator details
Typed name and signature of the Medical Staff Coordinator, telephone number, fax number and providing facility name.
How VA Form 10-0376a is completed
- 1
Enter identifying data
Fill in the provider's name, Social Security number, type of appointment and specialty in item 1.
- 2
Record each credential
List education, training, licenses and certifications, marking Y or N for primary source verification. The form notes that any item not verified at the primary source is listed with notation of information substituted.
- 3
Complete the clinical summary
Fill in the provider, facility and Service Chief names and the as of date in item 10, attach a copy of the clinical privileges, and use the remarks space or an additional sheet if needed.
- 4
Sign and add facility details
The Medical Staff Coordinator types a name, signs, and adds the telephone number, fax number and providing facility name.
Why fill Form 10-0376a on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Edition and notices
Where it goes
The form prints no mailing address. Item 10b addresses the brief to the receiving medical center.
Attachments
Item 8 asks for a copy of the clinical privileges granted, and the remarks space says to attach an additional sheet if necessary.
Burden
The notice estimates an average of 60 minutes per response and says submission of the information is voluntary.
Edition
JUL 2005, matching the July 2005 revision date on VA's form page. The footer says existing stock of VA Form 10-0376a, FEB 2002, will be used.
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Who uses VA Form 10-0376a?
The form names these people and facilities.
Official sources and the blank
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Questions about Form 10-0376a
What is VA Form 10-0376a?
It is the Credentials Transfer Brief, a VHA form that summarizes a provider's education, training, licenses, certifications and clinical privileges, with whether each item was verified at the primary source.
Who completes the Credentials Transfer Brief?
Items 11 and 12 are the typed name and signature of the Medical Staff Coordinator, and item 15 is the providing facility name.
What does primary source verified mean on the form?
Each education, training and license row has a Y or N column for whether it was verified at the primary source. The form notes that any item not verified there is listed with notation of information substituted.
What is attached to the brief?
Item 8 says to attach a copy of the clinical privileges granted. The remarks section says to attach an additional sheet if necessary.
Is giving the information voluntary?
The Paperwork Reduction Act notice says submission of this information is voluntary and failure to respond will have no adverse effect on any benefits to which you otherwise may be entitled.
Who can the information be shared with?
The Privacy Act notice lists releases such as to the National Practitioner Data Bank, State licensing boards, the American Medical Association and the Federation of State Medical Boards, where authorized by Title 38 and the Privacy Act.