REQUEST FOR MEMBERSHIP AND CLINICAL PRIVILEGES
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- Charlotte Augusta Shields
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1 REQUEST FOR MEMBERSHIP AND CLINICAL PRIVILEGES *Applicant Printed Name: *Denotes required fields (Last) (First) (M.I) (Degree) Maiden Name (Alias): (Last) (First) *DOB: *SSN Sex: Male Female *Applicant This will be used for the online application; all correspondence regarding membership will be sent to this . Please add IU Health to your safe sender list and check junk/spam if you have not received the application within 7 business days of your request. Credentialing Contact *Credentialing Contact Name: * Cred. Contact *Cred. Contact Phone: Applicant Home Address *Street: *City, State, Zip Code: *Phone #: Applicant Work Address Group/Practice Name: Street: City, State, Zip Code: Phone #: Fax#: Type of Membership and Clinical Privileges Requested: *Anticipated Start Date: Physician MD, DO, DDS Allied Health Practitioner Supv. Allied Health Practitioner Moonlighter Nurse Practitioner (NP) Registered Nurse (RN) Physician Assistant (PA-C) Licensed Practical Nurse (LPN) Certified Nurse Midwife (CNM) Certified Surgical Tech (CST) Clinical Nurse Specialist (CNS) Social Worker Podiatrist (DPM) Radiology Tech Psychologist (PhD) Cert. Reg. Nurse Anesthetists (CRNA) Membership is requested for the following facility(ies): IU Health - Arnett Hospital IU Health - Ball Memorial Hospital IU Health - Methodist/IU/Riley/Saxony/Morgan IU Health - North Medical Center IU Health - West Medical Center IU Health - Tipton Hospital IU Health - Bedford IU Health - Bloomington IU Health - Paoli IU Health - Blackford IU Health - White IU Health - Frankfort IU Health - Jay Glen Lehman Endoscopy Suite Ball Outpatient Surgery Center Endoscopy Center, LLC Saxony Surgery Center, LLC Senate Street Surgery Center, LLC Eagle Highlands Surgery Center, LLC Beltway Surgery Center, LLC South Surgery Center Riley Outpatient Surgery Center (ROC) Surgery Center Indiana Hand to Shoulder Center Multi-Specialty Surgery Center, LLC
2 IU Health has adopted an automated application to streamline its membership process. As part of the application process you will be required to fill out and attest to an online application along with several required online forms available through a personal Practitioner Home Page (PHP). In addition, you will be asked to upload required identification documents through the PHP. The link to your personal Practitioner Home Page will be sent to the on file (listed above). A separate with your password will follow. After you receive the information regarding your Practitioner Home Page, the following documentation will be required as part of the online application process to determine qualification for membership and clinical privileges requested: PHYSICIANS 1. Initial Online Application 2. Curriculum Vitae 3. Copy of current licensure to practice in the State of Indiana. If not currently licensed, documentation that application has been submitted to the Health Professional Licensing Agency. 4. Copy of current State of Indiana Controlled Substance Registration (CSR) or documentation that application has been submitted to the Health Professional Licensing Agency. 5. Copy of current Federal DEA. If you do not prescribe controlled substances, please submit a letter of explanation. 6. Copy of current professional liability insurance or documentation that insurance has been applied for. 7. Documentation of board certification or board eligibility status. 1. AHP Initial Application 2. Curriculum Vitae 3. Copy of licensure to practice in the State of Indiana. If not currently licensed, documentation that application has been submitted to the Health Professional Licensing Agency. 4. Copy of current State of Indiana Controlled Substance Registration (CSR) or documentation that application has been submitted to the Health Professional Licensing Agency. 5. Copy of current Federal DEA if applicable. 6. Copy of current professional liability insurance or documentation that insurance has been applied for. 7. Documentation of certification or board eligibility status if applicable. 8. Copy of Collaborative Practice Agreement, if applicable. 9. BLS, ACLS, PALS, NALS certification as indicated by privileges requested (BLS is required at a minimum). SUPERVISED 1. Supervised Allied Health Online Application 2. Current Job Description 3. Sponsor Letter from physician employer/supervisor 4. Copy of current professional liability insurance or documentation that insurance has been applied for. 5. Copy of current licensure or certification to practice as a Supervised Allied Health Practitioner. 6. BLS Certification Signature: Date:
3 *IU Health, IU Health North, and IU Health West have entered into exclusive arrangements with the following physician groups to provide clinical services at IU Health facilities in the areas of anesthesia, pathology, radiology and emergency medicine. In order to practice at an IU Health facility in these clinical areas, you will need to be a member of the appropriate group: Anesthesia: Anesthesia Consultants of Indianapolis, LLC (Adult only at North) and IU Anesthesiology Associates, LLC (Pediatric only at North) (Excluding Pain Management at all facilities) Pathology: Indiana Pathology Institute, P.C. Radiology: Indiana Radiology Partners, Inc. (Diagnostic only at North) Emergency Department: Emergency Medical Group Inc. *IU Health Bedford, IU Health Bloomington, IU Health Paoli, and Southern Indiana Surgery Center have entered into exclusive arrangements with the following physician groups to provide clinical services at IU Health facilities in the areas of anesthesia, pathology, radiology, and emergency medicine. In order to practice at an IU Health facility in these clinical areas, you will need to be a member of the appropriate group: Anesthesia: Bloomington Anesthesiologists, PC (Bloomington & Southern Indiana Surgery Center) (Excluding Pain Management) Pathology: Southern Indiana Pathologists (Bloomington & Paoli) Radiology: Southern Indiana Radiological Associates & NightShift Radiology (Bloomington & Paoli) and Indiana Radiology Partners (Bedford) Emergency Department: IU Health Southern Indiana Physicians (Bedford, Bloomington, & Paoli) *Please contact the appropriate facility Medical Staff Office if further clarification is needed PLEASE FAX THIS COMPLETED FORM TO (317) OR TO: IUHEALTHCVO@IUHEALTH.ORG
4 REQUEST FOR PRIVILEGES Department/Service Privileges are Requested (please check for each facility at which privileges are being requested): IU Health Academic Health Center (Methodist/IU/Riley/Saxony/Morgan) Anesthesia Nephrology Pediatric Surgery Peripheral Vascular Surg Cardiovascular Surgery Neurosurgery Physical Medicine & Rehab Dermatology Plastic Surgery Emergency Medicine* Ophthalmology Psychiatry Family Practice Oral/Maxillofacial & Dentistry Pulmonary/Critical Care Gastroenterology Orthopaedics Radiation Oncology Hematology/Oncology /Head & Neck Radiology* Infectious Disease Pathology* Surgery (General, Trauma, Transplant) Pediatrics, General Medical & Molecular Genetics Pediatrics, Specialty Vascular Surgery Certified Nurse Midwife Physician Assistant Psychologist Nurse Practitioner Podiatry IU Health West Hospital Anesthesia Rheumatology Pain Management Nephrology Dermatology Neurosurgery Emergency Medicine Family Practice GYN & Urogynecology Gastroenterology Gynecological Oncology Maternal Fetal Medicine Colon & Rectal Reproductive Endocrinology Hematology/Oncology Ophthalmology Oral/Maxillofacial & Dentistry Geriatrics Orthopaedics Infectious Disease Nurse Practitioner/CNS Physician Assistant Podiatry Pathology Pediatrics Neonatology Pediatric Pediatric Pulmonology Physical Medicine & Rehab Plastic Surgery Psychiatry Pulmonary/Critical Care Radiation Oncology Radiology* Vascular Surgery IU Health North Hospital Anesthesia* Radiation Oncology Family Medicine Pathology* Surgery Medicine Pediatrics Bariatric Surgery Adolescent Medicine Cardiovascular Surgery Dermatology Emergency Medicine* Community Pediatrics Neurosurgery Gastroenterology Critical Care/Pulmonology Ophthalmology Hematology/Oncology Developmental Pediatrics Oral/Madillofacial & Dentistry Endocrinology Orthopaedic Surgery Nephrology Gastroenterology Hematology/Oncology Pediatric Surgery Physical Medicine & Rehab Neonatology Plastic Surgery Psychiatry Pulmonary/Critical Care Radiology* Vascular Surgery Nurse Practitioner/CNS Physician Assistant Podiatry Psychologist
5 IU Health Arnett Hospital Anesthesia Infectious Disease Pediatrics Allergy & Immunology Physical Medicine & Rehab Neonatology Plastic Surgery Cardiovascular Surgery Nephrology Podiatry Critical Care Psychiatry Dentistry & Oral Max Surgery Pulmonary Medicine Dermatology Occupational Medicine Radiation Oncology Emergency Medicine Ophthalmology Radiology Endocrinology Orthopaedics Rheumatology Family Medicine Thoracic Surgery Gastroenterology Pain Management Urgent Care Pathology Hand Surgery Pediatric Vascular Surgery Hematology/Oncology Pediatric Surgery Hospitalist Pediatric Certified Nurse Specialist Nurse Practitioner - Neonatology Physician Assistant - Emergency Nurse Practitioner - Adult Nurse Practitioner - Pediatrics Psychologist Nurse Practitioner - Family Med Physician Assistant IU Health Ball Memorial Hospital Anesthesiology Medicine Pathology & Laboratory Medicine Ambulatory Teaching Pediatrics Critical Care Medicine (Med Ed)+ Physical Medicine Dental Nephrology Podiatry Dermatology Psychiatry Emergency Medicine -Remote Monitoring Psychiatry (Med Ed)+ Emergency Medicine (Med ED)+ Neurosurgery Pulmonary Disease Family Medicine Radiology Family Medicine Amb Teaching Ophthalmology Gastroenterology Orthopaedic Surgery Certified Nurse Midwife Physician Assistant Radiology Technologist Nurse Practitioner/CNS Psychologist Social Worker IU Health Tipton Hospital Anesthesiology Psychiatry Obstetrics/Gynecology Pulmonary Medicine Dental Oncology Radiology Dermatology Ophthalmology Rheumatology Emergency Medicine Oral Surgery Sleep Study Interpretation Endocrinology Orthopaedic Surgery Family Practice Vascular Surgery Gastroenterology Pathology Pediatrics Infectious Disease Plastic Surgery Podiatry Nurse Practitioner/CNS Physician Assistant Psychologist
6 Ball Outpatient Surgery Center, LLC Beltway Surgery Centers, LLC Eagle Highland Surgery Center,LLC Glen Lehman Endoscopy Suite, LLC Indiana Endoscopy Centers, LLC Indiana Hand to Shoulder Center Surgery Center Privileges Meridian South Surgery Center Riley Outpatient Surgery Center (ROC) Saxony Surgery Center, LLC Senate Street Surgery Center, LLC Multi-specialty Surgery Center East Washington Surgery Center Anesthesia Ophthalmology Plastic Surgery Dermatology Oral & Maxillofacial Surgery Podiatry Gastroenterology Orthopaedic Surgery Surgery /Head & Neck Neurosurgery Pediatric Surgery Vascular Surgery Physical Medicine & Rehab IU Health Bedford Hospital Emergency Care* Pediatrics Podiatry Medicine Psychiatry Thoracic Allergy Pulmonology Radiology Vascular Dermatology Surgery Telemedicine Endocrinology Anesthesia Family Medicine Pain Medicine Peds Gastroenterology Dental/Oral Surgery Peds Hematology Peds Psychiatry Ophthalmology Psychiatry Medical Oncology Radiology Nephrology Orthopaedics Sleep Disorders Pathology Occupational Medicine Plastic Surgery CRNA Nurse Practitioner/CNS Physician Assistant Psychologist IU Health Bloomington Hospital Anesthesia* Physical Med & Rehab Dentistry/Peds Dentistry Pain Medicine Pulmonary General Emergency Medicine* Sports Medicine Neurological Family Medicine Ophthalmology Medicine Palliative Medicine Oral/Maxillofacial Allergy/Immunology Pathology* Orthopaedic Pediatrics Critical Care Psychiatry Peds Surgery Dermatology Refer & Follow Plastic Surgery Endocrinology Radiology* Podiatry Gastroenterology Interventional Hematology/Oncology Radiation/Oncology Vascular Surgery Urgent Care Infectious Disease Cardiothoracic Nephrology Cardiovascular Surgery DaVinci Certified Nurse Midwife Physician Assistant Psychologist Nurse Practitioner/CNS
7 IU Health Paoli Hospital Anesthesiology Oncology/Hematology Surgery Emergency Medicine* Ophthalmology Medicine Orthopaedic Palliative Medicine Plastic Dermatology Pain Management Podiatry Family Medicine Pathology* Gastroenterology Radiology* Telemedicine Sleep Medicine Certified Nurse Midwife Nurse Practitioner/CNS Physician Assistant CRNA Southern Indiana Surgery Center Anesthesiology* Oncology Podiatry Cardiovascular Surgery Ophthalmology Psychiatry Gastroenterology Oral/Maxillofacial Radiology Orthopaedic Gynecology Laser Pain Medicine Lithotripsy Physical Medicine & Rehab Neuro Surgery Plastic Nurse Practitioner/CNS RN-Lithotripsy Physician Assistant
8 IU Health Blackford Hospital Anesthesiology Pathology* Emergency Medicine* Pediatrics General Dentistry Podiatry Psychiatry Radiology* Ophthalmology Orthopaedic Nurse Practitioner/CNS Physician Assistant Other Medicine Dermatology Family Medicine Pulmonology Telemedicine IU Health White Hospital Anesthesiology* Emergency Medicine Family Medicine General Dentistry Infectious Disease Oncology Ophthalmology Orthopaedic Pathology Podiatry Psychiatry Radiology Nurse Practitioner Physician Assistant CRNA CST Medicine Dermatology Gastroenterology Nephrology Pulmonology Sleep Medicine Sports Medicine IU Health Frankfort Hospital Anesthesia Emergency Medicine Family Medicine Gastroenterology Nephrology Orthopaedic Pathology Radiology Telemedicine CRNA Updated 4/24/2017
9 IU Health Jay Hospital Emergency Medicine Medicine Family Medicine Hematology/Oncology Hospice and Palliative Care Nephrology Pediatrics Pathology & Laboratory Psychiatry Radiology Surgery Anesthesia General Dentistry Ophthalmology Orthopaedics Podiatry CRNA Nurse Practitioner Physician Assistant
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