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Hospital Credentialing Application Form: What You Should Know
Medical School Affiliation: A. Medical School Name:. B. Accredited by the Joint Commission:. C. Hospital/Clinic Accreditation Number:. D. Current Facility Address: OR (Please provide alternate address if applicable). E. Facility Name: OR (Please provide alternate address if applicable). F. Facility Type: G. Location And City:. H. Address: OR (Please supply alternate address if applicable). I. Telephone Number:. J. Email Address:. K. Facility Type:. L. Medical Practice:. M. Facility Type:. N. Facility Type: (Use multiple fields if needed). O. Address: OR(Please supply alternate address if applicable). P. Facility Name: OR(Please supply alternate address if applicable). Q. Facility Type:. R. Hospital and Other Facility Affiliation:. Q. Name:. S. Address: OR(Please supply alternate address if applicable). T. Date of Birth:. U. Location:. V. Telephone Number:. VI. Email Address:. VII. Organization:. VIII. Current Facility Name:. IX. Facility Type:. X. Facility Type:. Z. Facility Type:. A1. Medical Institution (A):. A2. Medical Institution (B):. A3. Medical Institution (C):. A4. Medical Facility (CA): A5. Medical Facility (DC):. A6. Medical Facility (FL):. A7. Medical Facility (GE):. AA. Medical Institution (AL):. AB. Medical Facility (AR):. AC. Medical Institution (CC):. AD. Medical Facility (CO):. AF. Medical Facility (CT):. AG. Medical Facility (DE):. AH. Medical Facility (FL):. AI. Medical Facility (GA):. AI. Medical Facility (HI):. AH. Medical Facility (IA):. AI. Medical Facility (IL):. AK. Medical Facility (KS):. AK. Medical Facility (KY):. AL. Medical Facility (ME):. AL. Medical Facility (MT):. AM. Medical Facility (MT):. AO. Medical Facility (NC):. AO. Medical Institution (ND):. AP.
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