REQUEST FOR MEMBERSHIP AND CLINICAL PRIVILEGES

*Applicant Printed Name: ______*Denotes required fields (Last) (First) (M.I) (Degree)

Maiden Name (Alias): ______(Last) (First)

*DOB: ______*SSN______Sex: Male Female *Applicant Email: ______This email will be used for the online application; all correspondence regarding membership will be sent to this email. Please add IU Health to your safe sender list and check junk/spam if you have not received the application within 7 business days of your request. Credentialing Contact *Credentialing Contact Name: ______* Cred. Contact Email: ______*Cred. Contact Phone: ______Applicant Home Address *Street: ______*City, State, Zip Code: ______*Phone #: ______Applicant Work Address Group/Practice Name: ______Street: ______City, State, Zip Code: ______Phone #: ______Fax#: ______Type of Membership and Clinical Privileges Requested: *Anticipated Start Date: Physician MD, DO, DDS Allied Health Practitioner Supv. Allied Health Practitioner Moonlighter Nurse Practitioner (NP) Registered Nurse (RN) Physician Assistant (PA-C) Licensed Practical Nurse (LPN) Certified Nurse Midwife (CNM) Certified Surgical Tech (CST) Clinical Nurse Specialist (CNS) Social Worker Podiatrist (DPM) Radiology Tech Psychologist (PhD) Other: ______Cert. Reg. Nurse Anesthetists (CRNA)

Membership is requested for the following facility(ies): IU Health - Arnett Hospital Glen Lehman Endoscopy Suite IU Health - Ball Memorial Hospital Ball Outpatient Surgery Center IU Health - Methodist/IU/Riley/Saxony/Morgan Indiana Endoscopy Center, LLC IU Health - North Medical Center Saxony Surgery Center, LLC IU Health - West Medical Center Senate Street Surgery Center, LLC IU Health - Tipton Hospital Eagle Highlands Surgery Center, LLC Beltway Surgery Center, LLC IU Health - Bedford Meridian South Surgery Center IU Health - Bloomington Riley Outpatient Surgery Center (ROC) IU Health - Paoli East Washington Surgery Center IU Health - Blackford Indiana Hand to Shoulder Center IU Health - White Multi-Specialty Surgery Center, LLC IU Health - Frankfort Southern Indiana Surgery Center IU Health - Jay IU Health has adopted an automated application to streamline its membership process. As part of the application process you will be required to fill out and attest to an online application along with several required online forms available through a personal Practitioner Home Page (PHP). In addition, you will be asked to upload required identification documents through the PHP. The link to your personal Practitioner Home Page will be sent to the email on file (listed above). A separate email with your password will follow.

After you receive the information regarding your Practitioner Home Page, the following documentation will be required as part of the online application process to determine qualification for membership and clinical privileges requested:

PHYSICIANS 1. Initial Online Application 2. Curriculum Vitae 3. Copy of current licensure to practice in the State of Indiana. If not currently licensed, documentation that application has been submitted to the Health Professional Licensing Agency. 4. Copy of current State of Indiana Controlled Substance Registration (CSR) or documentation that application has been submitted to the Health Professional Licensing Agency. 5. Copy of current Federal DEA. If you do not prescribe controlled substances, please submit a letter of explanation. 6. Copy of current professional liability insurance or documentation that insurance has been applied for. 7. Documentation of board certification or board eligibility status. ALLIED HEALTH 1. AHP Initial Application 2. Curriculum Vitae 3. Copy of licensure to practice in the State of Indiana. If not currently licensed, documentation that application has been submitted to the Health Professional Licensing Agency. 4. Copy of current State of Indiana Controlled Substance Registration (CSR) or documentation that application has been submitted to the Health Professional Licensing Agency. 5. Copy of current Federal DEA if applicable. 6. Copy of current professional liability insurance or documentation that insurance has been applied for. 7. Documentation of certification or board eligibility status if applicable. 8. Copy of Collaborative Practice Agreement, if applicable. 9. BLS, ACLS, PALS, NALS certification as indicated by privileges requested (BLS is required at a minimum). SUPERVISED ALLIED HEALTH 1. Supervised Allied Health Online Application 2. Current Job Description 3. Sponsor Letter from physician employer/supervisor 4. Copy of current professional liability insurance or documentation that insurance has been applied for. 5. Copy of current licensure or certification to practice as a Supervised Allied Health Practitioner. 6. BLS Certification

Signature: ______Date: ______*IU Health, IU Health North, and IU Health West have entered into exclusive arrangements with the following physician groups to provide clinical services at IU Health facilities in the areas of anesthesia, pathology, radiology and emergency medicine. In order to practice at an IU Health facility in these clinical areas, you will need to be a member of the appropriate group:

Anesthesia: Anesthesia Consultants of Indianapolis, LLC (Adult only at North) and

IU Anesthesiology Associates, LLC (Pediatric only at North)

(Excluding Pain Management at all facilities)

Pathology: Indiana Pathology Institute, P.C.

Radiology: Indiana Radiology Partners, Inc. (Diagnostic only at North)

Emergency Department: Emergency Medical Group Inc.

*IU Health Bedford, IU Health Bloomington, IU Health Paoli, and Southern Indiana Surgery Center have entered into exclusive arrangements with the following physician groups to provide clinical services at IU Health facilities in the areas of anesthesia, pathology, radiology, and emergency medicine. In order to practice at an IU Health facility in these clinical areas, you will need to be a member of the appropriate group:

Anesthesia: Bloomington Anesthesiologists, PC (Bloomington & Southern Indiana Surgery Center)

(Excluding Pain Management)

Pathology: Southern Indiana Pathologists (Bloomington & Paoli)

Radiology: Southern Indiana Radiological Associates & NightShift Radiology (Bloomington & Paoli) and

Indiana Radiology Partners (Bedford)

Emergency Department: IU Health Southern Indiana Physicians (Bedford, Bloomington, & Paoli)

*Please contact the appropriate facility Medical Staff Office if further clarification is needed

PLEASE FAX THIS COMPLETED FORM TO (317) 968-1060

OR EMAIL TO: [email protected] REQUEST FOR PRIVILEGES Department/Service Privileges are Requested (please check for each facility at which privileges are being requested): IU Health Academic Health Center (Methodist/IU/Riley/Saxony/Morgan) Anesthesia Nephrology Pediatric Surgery Cardiology Neurology Peripheral Vascular Surg Cardiovascular Surgery Neurosurgery Physical Medicine & Rehab Dermatology Obstetrics & Gynecology Plastic Surgery Emergency Medicine* Ophthalmology Psychiatry Family Practice Oral/Maxillofacial & Dentistry Pulmonary/Critical Care Gastroenterology Orthopaedics Radiation Oncology Hematology/Oncology Otolaryngology/Head & Neck Radiology* Infectious Disease Pathology* Surgery (General, Trauma, Transplant) Internal Medicine Pediatrics, General Urology Medical & Molecular Genetics Pediatrics, Specialty Vascular Surgery ALLIED HEALTH Certified Nurse Midwife Physician Assistant Psychologist Nurse Practitioner Podiatry IU Health West Hospital Anesthesia Rheumatology Pathology Pain Management Nephrology Pediatrics Cardiology Neurology Neonatology Dermatology Neurosurgery Pediatric Cardiology Emergency Medicine Obstetrics & Gynecology Pediatric Pulmonology Family Practice GYN & Urogynecology Physical Medicine & Rehab Gastroenterology Gynecological Oncology Plastic Surgery General Surgery Maternal Fetal Medicine Psychiatry Colon & Rectal Reproductive Endocrinology Pulmonary/Critical Care Hematology/Oncology Ophthalmology Radiation Oncology Internal Medicine Oral/Maxillofacial & Dentistry Radiology* Geriatrics Orthopaedics Urology Infectious Disease Otolaryngology Vascular Surgery ALLIED HEALTH Nurse Practitioner/CNS Physician Assistant Podiatry IU Health North Hospital Anesthesia* Pediatrics Specialties Radiology* Family Medicine Adolescent Radiation Oncology Medicine Allergy Surgery Cardiology Cardiology Bariatric Surgery Dermatology Critical Care Medicine Cardiovascular Surgery

Emergency Medicine* Developmental Pediatrics General Surgery Gastroenterology Endocrinology Neurosurgery

Hematology/Oncology Gastroenterology Ophthalmology Internal Medicine Hematology/Oncology Oral/Madillofacial & Dentistry Nephrology Infectious Disease Orthopaedic Surgery Neurology Neonatology Otolaryngology

Physical Medicine & Rehab Nephrology Pediatric Surgery Psychiatry Neurology Plastic Surgery Pulmonary/Critical Care Pulmonology Urology Obstetrics & Gynecology Rheumatology Vascular Surgery Pathology* Other Pediatrics General

ALLIED HEALTH Nurse Practitioner/CNS Physician Assistant Podiatry Psychologist IU Health Arnett Hospital Anesthesia Infectious Disease Pediatrics Allergy & Immunology Internal Medicine Physical Medicine & Rehab Cardiology Neonatology Plastic Surgery Cardiovascular Surgery Nephrology Podiatry Critical Care Neurology Psychiatry Dentistry & Oral Max Surgery Obstetrics & Gynecology Pulmonary Medicine Dermatology Occupational Medicine Radiation Oncology Emergency Medicine Ophthalmology Radiology Endocrinology Orthopaedics Rheumatology Family Medicine Otolaryngology Thoracic Surgery Gastroenterology Pain Management Urgent Care General Surgery Pathology Urology Hand Surgery Pediatric Cardiology Vascular Surgery Hematology/Oncology Pediatric Surgery Hospitalist Pediatric Urology ALLIED HEALTH Certified Nurse Specialist Nurse Practitioner - Neonatology Physician Assistant - Emergency Nurse Practitioner - Adult Nurse Practitioner - Pediatrics Psychologist Nurse Practitioner - Family Med Physician Assistant Other: ______

IU Health Ball Memorial Hospital Anesthesiology Medicine Pathology & Laboratory Cardiology Medicine Ambulatory Teaching Pediatrics Critical Care Medicine (Med Ed)+ Physical Medicine Dental Nephrology Podiatry Dermatology Neurology Psychiatry Emergency Medicine Neurology-Remote Monitoring Psychiatry (Med Ed)+ Emergency Medicine (Med ED)+ Neurosurgery Pulmonary Disease Family Medicine Obstetrics & Gynecology Radiology Family Medicine Amb Teaching Ophthalmology Urology Gastroenterology Orthopaedic Surgery General Surgery Otolaryngology ALLIED HEALTH Certified Nurse Midwife Physician Assistant Radiology Technologist Nurse Practitioner/CNS Psychologist Social Worker

IU Health Tipton Hospital Anesthesiology Neurology Psychiatry Cardiology Obstetrics/Gynecology Pulmonary Medicine Dental Oncology Radiology Dermatology Ophthalmology Rheumatology Emergency Medicine Oral Surgery Sleep Study Interpretation Endocrinology Orthopaedic Surgery Urology Family Practice Otolaryngology Vascular Surgery Gastroenterology Pathology General Surgery Pediatrics Infectious Disease Plastic Surgery Internal Medicine Podiatry ALLIED HEALTH Nurse Practitioner/CNS Physician Assistant Psychologist Surgery Center Privileges Ball Outpatient Surgery Center, LLC Meridian South Surgery Center Beltway Surgery Centers, LLC Riley Outpatient Surgery Center (ROC) Eagle Highland Surgery Center,LLC Saxony Surgery Center, LLC Glen Lehman Endoscopy Suite, LLC Senate Street Surgery Center, LLC Indiana Endoscopy Centers, LLC Multi-specialty Surgery Center Indiana Hand to Shoulder Center East Washington Surgery Center Anesthesia Ophthalmology Plastic Surgery Dermatology Oral & Maxillofacial Surgery Podiatry Gastroenterology Orthopaedic Surgery Surgery Neurology Otolaryngology/Head & Neck Urology Neurosurgery Pediatric Surgery Vascular Surgery Obstetrics & Gynecology Physical Medicine & Rehab

IU Health Bedford Hospital Emergency Care* Pediatrics Plastic Surgery Medicine Psychiatry Podiatry Allergy Pulmonology Thoracic Cardiology Radiology Urology Dermatology Refer & Follow Vascular Endocrinology Surgery Telemedicine Family Medicine Anesthesia Neurology Gastroenterology Pain Medicine Peds Cardiology Hematology Dental/Oral Surgery Peds Neurology Internal Medicine General Surgery Peds Psychiatry Medical Oncology Ophthalmology Psychiatry Nephrology Otolaryngology Radiology Neurology Orthopaedics Sleep Disorders Occupational Medicine Pathology ALLIED HEALTH/ADVANCED PRACTICE PROVIDERS CRNA Nurse Practitioner/CNS Physician Assistant Psychologist

IU Health Bloomington Hospital Anesthesia* Physical Med & Rehab Dentistry/Peds Dentistry Pain Medicine Pulmonary General Emergency Medicine* Sports Medicine Neurological Family Medicine Obstetrics & Gynecology Ophthalmology Medicine Palliative Medicine Oral/Maxillofacial Allergy/Immunology Pathology* Orthopaedic Cardiology Pediatrics Otolaryngology Critical Care Psychiatry Peds Surgery Dermatology Refer & Follow Plastic Surgery Endocrinology Radiology* Podiatry Gastroenterology Interventional Urology Hematology/Oncology Radiation/Oncology Vascular Internal Medicine Surgery Urgent Care Infectious Disease Cardiothoracic Nephrology Cardiovascular Surgery Neurology DaVinci ALLIED HEALTH/ADVANCED PRACTICE PROVIDERS Certified Nurse Midwife Physician Assistant Psychologist Nurse Practitioner/CNS Other: IU Health Paoli Hospital Anesthesiology Oncology/Hematology Surgery Emergency Medicine* Ophthalmology General Surgery Medicine Orthopaedic Otolaryngology Cardiology Palliative Medicine Plastic Dermatology Pain Management Podiatry Family Medicine Pathology* Urology Gastroenterology Radiology* Telemedicine Internal Medicine Sleep Medicine Obstetrics & Gynecology ALLIED HEALTH/ADVANCED PRACTICE PROVIDERS Certified Nurse Midwife Nurse Practitioner/CNS Physician Assistant CRNA Other:

Southern Indiana Surgery Center Anesthesiology* Oncology Podiatry Cardiovascular Surgery Ophthalmology Psychiatry Gastroenterology Oral/Maxillofacial Radiology General Surgery Orthopaedic Urology Gynecology Otolaryngology Laser Pain Medicine Lithotripsy Physical Medicine & Rehab Neuro Surgery Plastic ALLIED HEALTH/ADVANCED PRACTICE PROVIDERS Nurse Practitioner/CNS RN-Lithotripsy Physician Assistant Other: IU Health Blackford Hospital Anesthesiology Pathology* Medicine Emergency Medicine* Pediatrics Cardiology General Dentistry Podiatry Dermatology General Surgery Psychiatry Family Medicine Neurology Radiology* Internal Medicine Obstetrics & Gynecology Urology Pulmonology Ophthalmology Orthopaedic Telemedicine Otolaryngology ALLIED HEALTH/ADVANCED PRACTICE PROVIDERS Nurse Practitioner/CNS Physician Assistant Other

IU Health White Hospital Anesthesiology* Oncology Urology Medicine Cardiology Ophthalmology Dermatology Sports Medicine Emergency Medicine Orthopaedic Gastroenterology Family Medicine Otolaryngology Internal Medicine General Dentistry Pathology Nephrology General Surgery Podiatry Neurology Infectious Disease Psychiatry Pulmonology Obstetrics & Gynecology Radiology Sleep Medicine ALLIED HEALTH/ADVANCED PRACTICE PROVIDERS Nurse Practitioner CRNA Other: Physician Assistant CST

IU Health Frankfort Hospital

Anesthesia Internal Medicine Pathology Cardiology Nephrology Radiology Emergency Medicine Neurology Telemedicine Family Medicine Orthopaedic Gastroenterology General Surgery

ALLIED HEALTH/ADVANCED PRACTICE PROVIDERS

CRNA Other:

Updated 4/24/2017 IU Health Jay Hospital Emergency Medicine Obstetrics & Gynecology Surgery Medicine Pathology & Laboratory Anesthesia Cardiology Psychiatry General Dentistry Family Medicine Radiology General Surgery Hematology/Oncology Ophthalmology Hospice and Palliative Care Orthopaedics Internal Medicine Otolaryngology Nephrology Podiatry Neurology Urology Pediatrics

ALLIED HEALTH/ADVANCED PRACTICE PROVIDERS CRNA Physician Assistant Nurse Practitioner Other: