All Information Will Be Kept Confidential
Please complete this form if you are an: Optometrist, Audiologist, CRNA, Anesthesiology Assistant, Nurse Clinician/Practitioner, Certified Nurse Midwife, Physician Assistant, Social Worker, CSAC, Professional Counselor, Marriage and Family Therapist, Physical Therapist or other mid-level provider.
The information requested is used for both the credentialing and in some cases for the privileging application process. Therefore, all application information must be completed and submitted before an applicant will be considered for participation and/or affiliation. Incomplete applications will result in delay of processing and the approval of privileges to practice within this system. Depending on timeliness of data collection, processing of applications may take two to four months. In the case of group practices or multiple providers, each provider must submit an application. Please use additional sheets when necessary.
