Credentialing Application Requests and Changes
Provider Name: (As listed on Professional License)
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
Credentialing Request
Credentialing Information Updates
Credentialing Requests: (check all that apply)
  ⓘ
(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)
Allied Health Privileges/Scope of Practice:
Comments:
Attachments:
After submitting your request, you will receive an email with further instructions
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