Application Request Form
(all information is required)
APPLICANT NAME:  (As listed on Professional License)

Last Name  
First Name
Middle
Professional Title
Phone
(ex: MD/DO, CNP, etc)
PLEASE SELECT ONE:  


CONTACT INFORMATION
Applicant's Direct E-mail Address:
YOUR APPLICATION and REAPPOINTMENTS WILL
BE SENT TO THIS EMAIL.

Information Used for Password Setup:

Applicant's Month/Day/ Year of birth:    
Applicant's Social Security number:   

A direct e-mail address is required and will be used for credentialing purposes and for other Fairview/HealthEast purposes if a legitimate need has been identified with the understanding that it is not to be used for publication or distribution to other organizations or individuals. The credentialing process may require email communications about confidential information. Applicant should provide an appropriate email address to maintain their confidentiality.


Anticipated Start Date:
Credentialing & Privilege Requests:
(check all that apply)








Credentialing Only Requests:





For medical staff membership at the listed hospitals for Physicians, Dentists, and Oral and Maxillofacial Surgeons, who desire to be associated with the facility but do not wish to exercise clinical privileges. See the applicable Fairview Hospital Medical Staff Bylaws for additional information.





Physician Non-Surgical Specialties/Privileges: (MD/DO only)
(check all that apply)
(If you have any questions about which facilities or privileges are appropriate to request, consult with your Department Chair or Hiring Manager)


































Physician Surgical Specialties/Privileges (MD/DO/DDS/DPM only)


















Allied Health Privileges/Scope of Practice:

























CREDENTIALING CONTACT (if applicable):

COMMENTS:
(ex: locums provider, provider currently in residency, specific list of clinics, etc.)