HSHS Physician Credentialing Request

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REQUEST FORM TO BE COMPLETED BY CLINIC/HOSPITAL REPRESENTATIVE, whenever possible.

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

* EMR (EPIC) Needed:

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

* Date of Request:

* Applicant's Last Name:

* Applicant's First Name:

Applicant's MI:

* Birth Date:

* Gender:

* Current Phone:

Current Fax:

* Current Email Address:

* Primary Specialty practicing in:

Sub Specialty practicing in (If Hospitalist include IM or FM):

Telemedicine Only:

* Check title that applies:

NPI #:

* Illinois License:

* Wisconsin License:

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

Board Certification:

Are you board certified in the primary area of practice you want privileges for:

Board certification specialty or subspecialty:

Date of Certification:

Date of Certification Expiration:

Are you ABMS Certified or AOA Certified:

*If Not Board Certified in primary area of practice:

Have you completed residency or fellowship training within the past five years?

Date of completion:

*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.

COMMENTS: (use this section to note any concerns we need to be aware of regarding this application)

Expected Hospital Start Date:

* Name of PRACTICE the provider will be employed by or contracted with to provide services:

Street Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Locum Tenen's Organization Name, if applicable:

Locum Tenen's Address:

Locum Tenen's City:

Locum Tenen's State:

Locum Tenen's Zip:

Locum Tenen's Phone Number:

Locum Tenen's Fax Number:

Sponsoring/Supervising Physician: (Allied Health Professionals Only)

Sponsoring/Supervising Physician Specialty:

CAQH ID#: (if employed by Sacred Heart Hospital, Eau Claire and/or St. Joseph's Hospital, Chippewa Falls)

Provider's inpatient services will require professional billing to file back to a clinic system. If Yes, provide clinic system.

Provider Clinic System:

Provider Primary Department in Clinic System:

*If you do not see the primary department you're looking for, please select "Other"

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 (Clinic/Hospital Representative)

* Requestor Name:

Requestor Phone Number:

* Requestor Email Address:

* Curriculum Vitae(CV) - Attach copy:

CREDENTIALS APPLICATION REQUEST FORM