Credentialing Application Requests and Changes Provider Name: (As listed on Professional License) Last Name First Name Middle Name Professional Title (ex: MD/DO, CNP, etc) Phone Provider's Direct Email Address A direct e-mail address is required and will be used for credentialing purposes and for other Fairview 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. Credentialing Contact Will be included on standard communications Last Name First Name Phone Email Credentialing Request Initial Application: New applicant to Fairview Additional Facility: Currently credentialed within Fairview and adding another location Additional Privilege: Currently credentialed within Fairview and adding a new privilege Credentialing Information Updates Name Employment/Malpractice Insurance Contact Information Sponsor/Collaborator License/DEA Disclosures Leave of Absence over 90 days Resignation of Privileges/Credentials Credentialing Requests: (check all that apply) Fairview Health Services Medical Staff ⓘ University of Minnesota Medical Center, M Health Fairview M Health Fairview Ambulatory Surgery Center in Maple Grove M Health Ambulatory Surgery Center at the Clinics & Surgery Center (CSC) in Minneapolis Fairview Medical Group Clinics - Credentialing Only Fairview Physician Associates - Credentialing Only 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) Allergy and Immunology Anesthesiology Cardiovascular Disease Clinical Genetics Critical Care Emergency Medicine Endocrinology Family Medicine Gastroenterology Hematology and Medical Oncology Hospice and Palliative Medicine House Physician Infectious Disease Internal Medicine Nephrology Neurology Newborn Transport Occupational Medicine Pain Medicine Pathology Pediatric Cardiovascular Disease Pediatric Critical Care Pediatric Emergency Medicine Pediatrics Physical Medicine and Rehabilitation Psychiatry Pulmonary Disease Radiation Oncology Radiology Rheumatology Sleep Medicine Sports Medicine Transplant Medicine Physician Surgical Specialties/Privileges (MD/DO/DDS/DPM only) Bariatric Surgery Colon and Rectal Surgery Colonoscopy and Snare Polyectomy Critical Care Dentistry Dermatology Neurological Surgery Obstetrics and Gynecology Ophthalmology Oral and Maxillofacial Surgery Orthopedic Surgery Otolaryngology Pediatric Surgery Plastic Surgery Podiatry Surgery (General) Thoracic and Cardiovascular Surgery Transplant Surgery UrologyAllied Health Privileges/Scope of Practice: Acupuncturist Anesthesia Monitoring Technician Audiologist Certified Nurse Midwife Certified Registered Nurse Anesthetist Chiropractor Clinical Nurse Specialist Genetics Counselor Mental Health Provider (Bachelor's Level) Mental Health Provider (Master's Level) Monitoring Technician (EEG, EP, EMG, IA, etc) Neurophysiologic Intraoperative Monitor Nurse Practitioner Optometrist Orthopedic Assistant (non-licensed) Orthopist Pefusionist Pharmacist/Medication Therapy Management Physician Assistant Psychologist Radiology Practitioner Assistant Registered Nurse Surgical Dental Assistant Surgical First Assist (non-Physician) Surgical TechnologistComments: Attachments: Submit Request After submitting your request, you will receive an email with further instructions