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Click the link below to review bylaws and policies to confirm that you meet the qualifications under eligibility criteria to apply at the requested hospital(s).

FACILITIES REQUESTED FOR CREDENTIALS

Select each facility credentials are needed

Illinois Facilities
Wisconsin Facilities

EMPLOYED BY

Please check any of the following, if applicable.

Illinois
Wisconsin

ADDITIONAL DETAILS

Application fee required: Total of $300.00 application fee required for HSHS Hospitals listed above. HSHS Hospital employed colleagues are exempt. (Invoice will be included with application packet)

* Check title that applies:

* FOR PHYSICIANS TO COMPLETE ONLY - (AHP'S refer to privilege form for criteria)

Board Certification:
*If Not Board Certified in primary area of practice:
*POLICY REQUIREMENTS FOR BOARD CERTIFICATION:
Illinois
See Bylaws and Policies for Board Certification Requirements

Wisconsin
*If Yes, you must achieve board certification in primary area of practice within the five years from date of completion of residency or fellowship training.

**If not board certified, or do not meet policy requirements, contact the specific facility wishing to obtain privileges to discuss.

ALTERNATE COVERAGE (Physicians only)

List WHO would provide alternate coverage in your absence. Must be members of the Medical Staff of the specific hospital(s) that privileges are being requested for.

*This section will appear after they are selected above in the Facilities section.

ALL application materials will be sent electronically to the APPLICANT through an online application website.
*If clinic and/or designee will be assisting the applicant, the applicant (him/herself) will need to authorize users.
Source of Request