Medical Staff / APP Intake Form - Bronson Health 2026

1. Click ‘Get Form’ to open the Medical Staff / APP Intake Form in the editor.
2. Begin by entering your Provider Name, Email, and Telephone number in the designated fields. Ensure accuracy as this information is crucial for communication.
3. Fill in your NPI number and Specialty. This helps identify your qualifications and area of expertise.
4. Indicate your gender and provide the name of your Supervising Physician if applicable. This section is important for compliance and record-keeping.
5. Select the appropriate box for the service you are requesting, such as Initial Application, and specify the requested location(s) from the provided options.
6. Complete sections regarding employment status, including details about any locum tenens companies if relevant.
7. Finally, ensure that all fields are filled out completely before submitting. Return the form along with a current CV to the Medical Staff Office.

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