Healthcare Medical Staff Application

Healthcare Medical Staff Application

Applicant Information

Full legal name:

Date of birth:   Gender:

Licensure and Certifications

Issuing state:   Issue date:   Expiration date:

DEA issue date:   DEA expiration:

 Board certified

Education, Training, and Specialty

Graduation year:   Residency program:

Employment History (Most Recent First)

Position/title:   Dates of service:

Position/title:   Dates of service:

Position/title:   Dates of service:

Professional References

Professional Liability Insurance and Claims

Policy number:   Per claim / aggregate limits:

 I have been named in a malpractice claim or suit

Background and Disciplinary Actions

Please indicate whether any of the following have occurred. For each checked item, provide a detailed explanation below.

 Licensing board action, investigation, or restriction
 Hospital privileges denied, revoked, reduced, suspended, or not renewed
 Criminal conviction or pending criminal charge
 Exclusion from federal or state healthcare programs

Requested Clinical Privileges and Availability

Authorization, Attestations, and Consent

I certify under penalty of perjury that the information provided in this application and any accompanying documentation is true, complete, and correct to the best of my knowledge. I understand that omission, misrepresentation, or falsification of information may result in denial of appointment, termination of privileges, or other corrective action.

I authorize the medical staff office, affiliated institutions, licensing boards, current and prior employers, references, and insurers to release to the reviewing committee any information that may be relevant to my application, including verification of education, training, licensure, clinical competence, malpractice history, and background investigations. I release from liability all individuals and organizations who provide such information in good faith.

I understand that this application in no way guarantees appointment or clinical privileges. I agree to comply with applicable facility bylaws, rules, policies, and standards of professional conduct. I consent to periodic recredentialing and to the use and disclosure of credentialing information for purposes related to my application and ongoing privileges.

Attachments Required

Attach copies of valid licensure, DEA registration (if applicable), board certification, current professional liability declarations, curriculum vitae, and any other supporting documentation required for review.

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