Alaska Native Medical Center

Medical Staff Office; 4315 Diplomacy Drive; Anchorage, AK 99508; Phone: (907) 729-1973 Fax: (907) 729-1542

APPLICATION REQUEST FORM & SERVICE CHIEF INITIAL REFERENCE for APPLICANT ( ARF / SCIR )

Applicant’s Name: / Degree: / Specialty: / Board Certification:
Yes No N/A
SSN: / DOB: / Place of Birth: / E-Mail Address:
Applicant’s Complete Mailing Address: / Contact # for Applicant:
Contact # and Name for Person Handling Application:
Medical/Professional School: / Current Program:
Date of Graduation: / NPI#
Do you have an Alaska License?
Yes (If yes, # )
No
Applying / List the States in which you hold or have held any type of medical license(s):
Training Purposes
 ANP/PA Student
 Dental Student
 Medical Student
 Resident
 Fellow
 Practitioner
Refresher / Alaska Native Tribal Health Consortium (ANTHC)
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Department______Rotation Dates______/ Southcentral Foundation (SCF)
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Signature of individual obtaining above information: / Printed Name of individual obtaining above information: / Date:
** APPLICANT, PLEASE NOTE: Once the Medical Staff Office receives this form, you will be mailed a complete application packet to apply. **

* * APPLICANT - DO NOT WRITE BELOW THIS LINE * *

Service Center Medical Director or Designee of Corresponding Service Center to complete below
Are the services being provided by the applicant:  Billable by ANTHC/SCF  Not Billable
*Medical Students, ANP/PA Students are Non-Billable
Will the provider be covered under:  FTCA or  The Training Program will be providing their own malpractice coverage
Name of Carrier ______
Signature of individual obtaining above information: / Printed Name of individual obtaining above information: / Date:

Service Center Medical Director of Corresponding Service Center To Complete Below

SCMD Signature: Printed Name:
Or Designee
Date:
Executive Signature: Printed Name: Susan E. Miklavcic, CPCS, CPMSM, Director MSO
Date:

Revised 6/9/2011