Med Staff Application

Please list practitioner name affiliated with this fee:*

Please enter the Practitioner Name.
First Name:*

Please enter your first name.
Last Name:*

Please enter your last name.
Company Name:
Street Address 1*

Please enter your address.
Street Address 2
City*

Please enter your city.
State*

Please enter your state.
Zip*

Please enter your zip.
Phone Number:*

Please enter your phone number.
Email:*

This isn't a valid email address.

Please enter your email address.
Payment Information
Amount *
- Joining the Staff (non-refundable fees)
- Medical Staff New Application: ($400.00)
- Medical Staff New Application + Penalty (400.00 plus 500.00) ($900.00)
- Allied Health New Application: ($200.00)
- Allied Health New Application + Penalty (200.00 plus 500.00) ($700.00)
- Medical Staff Reappointment Fee: ($360.00)
- Allied Health Professionals Reappointment Fee: ($150)
- NOT Joining the Staff (non-refundable fees)
- Request to Observe a Specific Patient/Procedure (not scrub): ($100.00)
- Modified Credentialing Application (Temporary Privileges for Care of a Specific Patient): ($150.00)
Please select the value.
Comment:
Credit Card Type*

Please enter your credit card type.
Credit Card Number:*

This isn't a valid credit card number.

Please enter your credit card number.
Credit Card Expiration:*
/
Please enter the card expiration.
Security Code:*

Please enter your security code.