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Process for Application
Medical and Dental Staff
Each applicant has the obligation to assist with obtaining
information necessary to complete his/her application. The
hospital’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.
Information required from the Applicant:
1 Copies
of state licensures (NC and other states).
2 Copy
of DEA certificate.
3 Copy
of Cover Sheet for current Professional Liability Insurance
within
limits of $1 million/$1 million.
4 Copy
of Cover Sheet for all insurance policies held during the
past
five years.
5 Copy
of College Degree.
6 Copy
of Medical Degree.
7 Complete
list of Internship, Residency and Fellowship.
8 List
of all professional affiliations/employers for the last five
(5) years.
9 Three
professional reference letters, which must be from colleagues
within the same professional discipline who have
observed the
Applicant’s clinical practice.
10 Board
Certification information (if applicable).
11 Completed
criminal history form.
12 ECFMG
information (if applicable).
13 Current
resume/CV.
14 Copy
of current driver’s license.Please obtain a copy of
the
Application and complete page 4A
with chronological dates. Please
include fax numbers and current addresses.
The Medical Staff Office will verify all of the above listed
required application data, and will obtain the following additional
information:
1 An
AMA Physician Master File.
2 A
National Practioner Databank Query.
3 A
five-year malpractice history.
Verification of information on the application form takes
approximately six (6) weeks. If difficulties are encountered
in receiving the information, you will be asked to assist
with the process to obtain needed information. You may be
asked to provide specific information related to clinical
privileges requested (i.e., number of procedures performed,
verification of additional training, and education).
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 (10) weeks.
Please take the time to make sure that 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 $250.00 (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.
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Medical
and Dental Staff