Credentialing Application for Hospitals and Facilities 2025

1. Click ‘Get Form’ to open the Credentialing Application in our editor.
2. Begin by filling out your personal information in the 'Practitioner Information' section. Ensure you provide your last name, first name, date of birth, and other required details accurately.
3. Move on to the 'Credentialing Contact Information' section. Here, specify your preferred method of contact and provide relevant contact details such as phone number and email address.
4. In the 'Professional Education and Training' section, list all relevant educational experiences. If additional space is needed, attach separate sheets and reference the questions accordingly.
5. Complete the 'Clinical Employment/Practice History' section chronologically. Be thorough in detailing your employment history since completing post-graduate training.
6. Finally, review all sections for completeness. Sign and date the Authorization, Attestation, and Release on page 6 before submitting your application.

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