(The following schedules are part of the application that may be downloaded and used if additional copies are needed.)

 PLEASE NOTE:

Keep a copy of your original application, either saved on your computer or a hard copy for future use.

 Maintain the form(s) by updating with new information as needed.

Every time you are credentialed, the Hospital, Health Plan and/or other Healthcare Entity(ies) will require your signature and date on a new "Authorization and Signature" page. This form allows the plan or hospital to verify the information you've included on your application by confirming it from primary sources. It also contains an attestation stating that the information on your application is current and true to the best of your knowledge.

 Please review each copy of the application form prior to submitting to ensure that all sections are complete (incomplete forms will not be accepted!). Remember, in order for your application to be considered complete, you must submit Part One & Part Two simultaneously.