MedStaff Requests   
             
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             MedStaff Requests  

        
            DATE: 12/7/2009CREDENTIALING VERIFICATION ORGANIZATION
            PHONE: (480) 684-5050
            FAX: (480) 684-7202 

            Request for Initial Application (the full Initial Application will 
            be sent within 7 days of receipt of this request) 
            I am applying for privileges/membership to: (check all that apply) 
                  Banner Baywood Medical CenterBanner Gateway Medical Center
                  Banner Behavioral Health Hospital-ScottsdaleBanner Good 
                  Samaritan Medical Center
                  Banner Boswell Medical CenterBanner Heart Hospital
                  Banner Del Webb Medical CenterBanner Surgery Centers
                  Banner Desert Medical CenterBanner Thunderbird Medical Center
                  Banner Estrella Medical CenterPage Hospital
            ALL OF THE FOLLOWING INFORMATION IS REQUIRED.
            (if information is pending or not applicable, please indicate) 
                  Medical StaffAllied HealthCommunity Based
            (Please check one) * Required 
            First Name * RequiredMiddle NameLast Name * RequiredDegree * 
Required

            Primary Office / Mailing Address * Required


            City * RequiredState * RequiredZip * Required
                AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD 
              ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN 
              TX UT VA VT WA WI WV WY
            Telephone * RequiredFaxE-Mail Address (application will be sent to 
            this e-mail address) Please enter a valid email address 


            Group Name (or sponsoring physician if Allied Health) * Required

            Covering Physician(s)

            Date of Birth * Required Please enter a valid date in the form 
            MM/DD/YYYY Social Security # * Required Enter a SSN w/dashes AZ 
            License #

            UPIN #NPI # * Required Must be 10 digits DEA #

            Malpractice Ins. Carrier * RequiredPolicy #

            Name of InsuredAmount of Coverage

            Effective Date Please enter a valid date in the form MM/DD/YYYY 
            Expiration Date Please enter a valid date in the form MM/DD/YYYY 


            Have you had or are there currently any pending claims/complaints 
            filed against you within the last ten years? * RequiredYesNo


            Primary Specialty * Required
            Specialty Board/Certification Status   Certified   Qualified   Not 
            Certified 
            Primary& Subspecialty
            ABMS     AOA     Other    

            Medical School Attended (or Medical Training if Allied Health)  * 
            Required 

            Medical School Address

            CityStateZip
                AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD 
              ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN 
              TX UT VA VT WA WI WV WY
            Graduation Date (mm/dd/yy)Degree Earned


            Post-Grad Training
            InternshipSpecialty

                  Facility

                        Facility Address

                        CityStateZip
                            AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS 
                          KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY 
                          OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

                        Dates Attended:From Please enter a valid date in the 
                        form MM/DD/YYYY To Please enter a valid date in the form 
                        MM/DD/YYYY 
                         


            ResidencySpecialty

                  Facility

                        Facility Address

                        CityStateZip
                            AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS 
                          KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY 
                          OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

                        Dates Attended: From Please enter a valid date in the 
                        form MM/DD/YYYY To Please enter a valid date in the form 
                        MM/DD/YYYY 
                         


            FellowshipSpecialty

                  Facility

                        Facility Address

                        CityStateZip
                            AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS 
                          KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY 
                          OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

                        Dates Attended:From Please enter a valid date in the 
                        form MM/DD/YYYY To Please enter a valid date in the form 
                        MM/DD/YYYY 
                         



            Primary Hospital
            Facility

            Address

            CityStateZip
                AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD 
              ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN 
              TX UT VA VT WA WI WV WY
            TelephoneFax

            Date on Staff:From Please enter a valid date in the form MM/DD/YYYY 
            To Please enter a valid date in the form MM/DD/YYYY