Request for Membership and Clinical Privileges
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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