QUESTION:
This week’s question is taken from those submitted at the January 15-16, 2026 Complete Course for Medical Staff Leaders, held in Amelia Island.

Sometimes it’s very tempting to call a colleague you may know at another hospital to clarify the details of an applicant.  While I believe this is done routinely, is it legally permissible if the applicant has not declared this person a reference?

ANSWER FROM HORTYSPRINGER ATTORNEY RACHEL REMALEY:
As a general rule, it is perfectly acceptable (and appropriate) to contact anyone who may have any information that is relevant to an applicant’s qualifications.

This is America – so of course this has been litigated.  Check out what the United States District Court for the District of New Jersey said in this 2014 case (where a physician alleged wrongdoing by a Credentials Committee chair, who contacted individuals not listed by the applicant on her application):

“As to [the Credentials Chair’s] request for information from non‑references…affirmative contact with these individuals, that is, without prior clearance for such action from Dr. Pal, reflects a diligent and comprehensive investigation in connection with her application for privileges…”

Pal v. Jersey City Medical Center (D.N.J. Oct. 24, 2014)

So, who can you contact?  Anyone who may have information about the applicant’s clinical skill, experience, training, professional conduct, health status, etc.  You likely have a statement in your Medical Staff Bylaws and on your Medical Staff application forms that states something to this effect (virtually all organizations do).

The “usual suspects” for affiliation verifications/references include other health care facilities where the applicant is employed or has been employed, or has held medical staff membership or clinical privileges.  Department chairs from current and previous organizations, as well as residency program directors (if recently out of training), and current and past employers are also often contacted.

But, what about a nurse supervisor at a facility that has reported interpersonal conduct issues by the practitioner?  What about the applicant’s arresting or probation officer?  An ex-wife who filed a restraining order?  Yes to all of these!  Anyone who may have information relevant to the qualifications of the practitioner to be a medical staff member (including maintaining orderly operations of the hospital) or to exercise privileges (including anyone who may have information about health status, reliability, clinical performance, education, training) can be contacted and asked for information.

To get back to your question – you specifically asked whether you can contact a colleague you know.  Of course (as noted above), the answer is yes (we really do mean anyone who may have information about the applicant, including anyone who may be able to share real life observations or other information).  But, here’s the kick – whenever you request and/or obtain information about an applicant, that should be documented in the credentialing file.  Therefore, before you call in a personal favor to a friend, realize that your contact with that individual needs to be documented in the file and anything they tell you will not be “off the record.”

So, if you plan to contact a personal friend, acquaintance, or colleague to request information, remember to treat the contact and request with the same formality that you would treat other requests.  If you are asking for important information, trying to clear up concerning rumors or verify whether the applicant has made a misrepresentation, etc., it may be best to make the request for information in writing (and to supply a copy of any authorization/release that your applicant has signed).

Never promise that information revealed to you will be kept secret (this is a promise you cannot keep!).

And, if your friend/colleague holds a leadership position at another facility (e.g., they are the chair of credentials or department chair at the facility where the applicant recently held privileges), remember that they have legal obligations of confidentiality with respect to their proceedings as medical staff leaders and when they act in those roles they are agents of the facility.  Accordingly, it may be best in those cases to direct your request to the facility itself, rather than the individual (so that the individual is not put in a difficult position).

If you have a quick question about this, e-mail Rachel Remaley at rremaley@hortyspringer.com.