Hamilton Health Sciences

Credentials FAQ

New Appointments

How does the HHS/SJHH credentialing process work?
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Professional Staff applicants contact their respective Department Chief and the Chief will send an initial recommendation to the Common Credentials Office to initiate application. An application will be emailed to the Professional Staff to complete and return within 120 days (at which time the application will become null and void). Upon verification of the completed application and all associated documents, the Department Chief will provide the Common Credentials Office with a final recommendation.

The credentialing process ensures due process and fair administrative procedure and is compliant with the requirements in the Ontario Public Hospital Act. Hamilton Health Sciences/St. Joseph’s Healthcare Hamilton are required to comply with the process and procedures as outlined in the Bylaws.

What documentation does HHS/SJHH require of a prospective member?
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The application for Professional Staff appointment contains the list of information and documents that an applicant must produce. Key elements of the required information are: Royal College certification (or membership with applicable governing body, i.e. College of Midwives), proof of license and liability insurance coverage, curriculum vitae, names of 3 references, a statement of agreement, a declaration and consent to release information.

For Further detail regarding qualifications and criteria for Appointment to the Professional Staff please See HHS Bylaws Article 16.03 and SJHH Bylaws Section 7.

Is an Academic Appointment required?
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Hamilton Health Sciences and St. Joseph’s Healthcare Hamilton are major teaching Hospitals whose mission includes patient care, education and research. Individuals appointed to the Associate/Active/Clinical Scholar Professional Staff category are expected to undertake mutually agreed upon clinical and academic responsibilities. An Academic Appointment with McMaster University is a requirement of an Active and Associate Staff appointment. Some exemptions apply as per the Hospitals Administrative and Professional Staff By-laws and Rules and Regulations.

What is a Temporary Appointment with Temporary
Privileges and when are they granted?
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A Temporary Appointment with Temporary Privileges is often used at HHS/SJHH to permit a practitioner to begin practice in an HHS/SJHH facility before his/her Application for appointment has been reviewed and approved by the Board. Under these circumstances, and upon receipt of a completed application for appointment, the relevant Department Chief may grant a Temporary Appointment with Temporary Privileges to the practitioner which will remain in effect only for the purpose or period specified, or pending the Board’s review of the practitioner’s Application for Appointment.

Is there a committee of the Professional Staff that reviews applications?
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Yes, the Credentials Committee, a standing committee of the Medical Advisory Committee (MAC) is responsible for reviewing applications for appointment and renewal of membership and making recommendations regarding each applicant to the applicable Board.

Who should I contact if I want to change or review my current clinical privileges?
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It is recommended that changes to the Professional Staff category or privileges be discussed with the Head of Service and/or Department Chief. If the relevant medical leaders are supportive of the change, a form requesting the change may be obtained from the HHS Credentials Office. All inquiries can also be directed to the Credentials Office at

Can I request privileges in more than one department?
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Yes. An appointment to the Professional Staff granted by the Board specifies the Category, the Department, Specialty, and Privileges. An applicant is normally appointed to a “primary Department” but may also be appointed to another Department where advantageous to the Department and the member.

What does "eligibility for Professional Staff privileges" mean?
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“Eligibility” refers to whether an applicant meets all the criteria outlined in the Bylaws to become a member of the Professional Staff.

Is an N95 Mask fit test required for appointment to the Professional Staff?
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Hamilton Health Sciences & St. Joseph’s Healthcare Hamilton mandate N95 compliancy for all Professional Staff, in accordance with HHS/SJHH Respiratory Protection Protocol. All Professional Staff are required to complete their N95 mask fit test prior to an appointment being granted at HHS. Fit testing must be renewed every two years as per CSA Standard Z94.4-11 Selection.

Why do I need to participate in the reappointment process?
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The HHS/SJHH by-laws, as informed by the Ontario Public Hospitals Act affirms that appointments to the Professional Staff are for a 1 year period of time. Reappointment to the Professional Staff requires a member to complete an electronic reappointment application form. This form is provided by the Common Credentials Office in advance of the conclusion of the member’s current appointment term. The completed form is reviewed by Department Chiefs, the Credentials Committee and the Medical Advisory Committee (MAC) before being presented to the Board.

What do I need to submit for review and renewal of membership?
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Professional Staff members must complete an online application which includes confirmation of valid CMPA & CPSO for Medical Staff. Dental/Midwifery and Nurse Practitioner Professional Staff must provide proof of valid license and liability insurance coverage. Proof of updated N95 mask fit certificate is required if the mask fit test was done at a facility other than HHS/SJHH. Additional documentation such as Curriculum Vitae and CME credits/updated training may be requested at a Departmental level.

Is the reappointment process changing?
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Yes. As of 2016, Hamilton Health Sciences & St. Joseph’s Healthcare Hamilton have changed to an automated reappointment process with the electronic credentials management system called CMaRS (Clinician Management and Reappointment System). This change is a result of current system attrition, evolving technology and eliminates the lengthy and onerous paper-based professional staff reappointment process. As of 2017, all Professional Staff will be subject to the online reappointment process.

Is there a charge for membership renewal?
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Yes. There is an annual fee of $50 associated with the reappointment process.

Why is there a fee of $50, and what will it be used for?
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The $50 fee will offset the cost of the electronic system – any residual funds will be re-invested into physician quality improvement initiatives.

Do I have to pay the $50 fee twice if I have an appointment at HHS and SJHH?
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No. You will pay one re-appointment fee of $50. If you have an appointment at both facilities you will process both appointments at the same time through the e-credentialing system.

Is an N95 Mask fit test required for annual reappointment?
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Yes. Hamilton Health Sciences & St. Joseph’s Healthcare Hamilton have implemented mandatory N95 compliancy for all Professional Staff, in accordance with HHS/SJHH Respiratory Protection Protocol. All Professional Staff are required to complete their N95 mask fit test as part of the annual reappointment process and Fit testing must be renewed every two years as per CSA Standard Z94.4-11 Selection.

What email address will the re-appointment link be sent to?
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The Common Credentials Office will send the online reappointment link to the preferred email address on file. To update your preferred email, please email the Common Credentials office at

What if I did not receive an email with my username and password
to access the CMaRS application?
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If you have not received an email with login please contact credentials at

How can I ensure my information and data is secure?
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All communication with the CMaRS application is encrypted using industry standard SSL, making the transfer of information private and secure. The application and data is stored in secure data centres. If you are using WiFi to connect to the internet you should always use a secure connection for any sensitive data.

What if I need to make a change to my application?
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There is an opportunity to request a change and list the request via the online application. This change will be submitted to your department Chief and the Common Credentials Office for processing and approval. Your re-appointment application will then follow the normal process of approval as outlined in your professional staff by-laws.

I can’t book an N95 mask fit test date prior to the
reappointment application due date – what do I do?
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Applicants will be able to proceed with their application without an updated N95; however, confirmation that mask fit appointment has been booked is required. Simply submit confirmed N95 test date in the comment box of your online application.

To update your N95, please ensure you are following the HHS & SJHH processes to book your test. NOTE – drop ins to the Employee Health Office will not be accommodated – please ensure you book through the appropriate process.

How do I book an N95 mask fit test at HHS?
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To book an appointment at HHS, please visit the following webpage.
You may also follow the instructions below:

• Go to the HHS internal website
• Click on Health Safety & Wellness
• Select Safety Services
• Click N95 Fit Testing Clinic (right hand side)
• Click book your appointment today.
• OR — visit one of the clinics listed on the Health Safety & Wellness website.

(As a reminder, appointments are booked every 20 minutes; please ensure that you are prompt for a booked appointment to avoid delays).

How do I book an N95 mask fit test at SJHH?
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Please contact your department’s Chief Assistant to book an appointment.

What if I have troubles with the system – who do I contact to troubleshoot?
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You can contact the Common Credentials Office at

I completed my application, but was not prompted to remit payment?
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If you utilize the RMA service, your payment is covered.

Contact our Team
Lori Arbeau
Credentials Associate – Reappointments
ext. 75273
Huyam Abdelhalim
Credentials Associate – Reappointments (Niagara Health)
ext. 75461
Carla Mans
Credentials Associate – New Appointments
ext. 72340
Kristi Van den Heuvel
Credentials Coordinator
ext. 44384
Do you have more questions?
If you have any further questions please contact the common credentials office at:
Hamilton Health Sciences • Hamilton, Ontario • 905.521.2100

Disclaimer: Hamilton Health Sciences (HHS) offers Google Translate to better facilitate access for our community. However, HHS makes no claims regarding the accuracy of translations. Any and all health information should be verified by a health care professional.