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

Last Name  
First Name
Middle
Professional Title
Phone
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.

Credentialing & Privilege Requests: (check all that apply)









Credentialing only Requests: (For medical staff statuses at the listed locations as well as Physicians, Dentists, and Oral and Maxillofacial Surgeons, who desire to be associated with the facility but do not wish to exercise clinical privileges on an inpatient basis. See the applicable Fairview Hospital Medical Staff Bylaws for additional qualifications, prerogatives and responsibilities).





SPECIALTIES/PRIVILEGES:

Primary Practicing Specialty and/or Additional Privilege Requesting:  

All Other Practicing Specialty(ies):

CREDENTIALING CONTACT (if applicable):