Process for Application

Allied Health Application Process
Each applicant has the obligation to assist with obtaining information necessary to complete his/her application. The Health System’s credentialing policy requires primary source verification of reference. The application is considered complete when the required information has been received and verified by the Medical Staff Office IF APPLICABLE.

Information required from the Applicant: (If Applicable)

• Copy of a government Issued Photo ID
  (Driver’s License, Passport Photo, Resident Visa Care).
• Copies of ALL state licensures (NC and other states).
• Copy of DEA Certificate
• Copy of Cover Sheet for current Professional Liability Insurance with limits of $1 million/$1 million.
• Copy of Cover Sheet for all insurance policies held during the past five years.
• Copy of College Degree/Special Training/On the Job Training.
• Review of Orientation Manual and completion of Post-Test.
• List of all professional affiliations/employers for the last five (5) years.
• Three professional reference names, telephone number and fax numbers, which must be from colleagues within the same professional discipline who have observed the applicant’s clinical practice (letters will be sent out from the Medical Staff Office).
• Certification information.
• Completed criminal history form.
• Documentation of TB skin test within six (6) months (if you are a TB skin test reactor, please furnish a copy of a negative chest x-ray).
• Urine Drug Screen (this test must screen for methamphetamines, amphetamines, cocaine, opiates and marijuana (THC)) – confidential results are to be faxed to Medical Staff Relations (878-6707 or 878-6248) from the healthcare provider/facility who administered the test*.
• Current resume (CV).
• Signature of Sponsor.
• Military Service: If you have served in the military a copy of one of the following is needed: Discharge Papers, Statement of Orders, or Duty History Form

An interview may be requested to clarify information obtained during the verification process. You will be notified if this is necessary. Additional references may be requested. Following receipt of all required information, your application will be reviewed by the appropriate Section Chief, Credentials Committee, Medical Executive Committee, and the Board of Trustees. After the COMPLETED application is received, the credentialing process takes approximately ten weeks.

Please take the time to make sure your application is as thorough and accurate as possible. Please return your COMPLETED application, along with a check made payable to High Point Regional Health System in the amount of $150.00 (Application Fee).

In the event that you have any questions while completing your application or any issues that you would like to discuss, please feel free to contact Geraldine Mulcahy at (336) 878-6082 or gmulcahy@hprhs.com. Please understand that Internet correspondence may not be secure

Application for download

Allied Health