High Point Regional Health System Date Application Received: ______

601 North Elm Street

P.O. Box HP-5

High Point, NC 27261

(336) 878-6000

Date:______

Dear Applicant to the Medical/Dental Staff:

Thank you for your interest in High Point Regional Health System. We at HPRHS are very proud of our Medical/Dental Staff and the quality of care they provide. With exemplary care and citizenship in mind, we have criteria which must be met in order to apply to our Health System.

Criteria:An applicant must have completed an approved residency training program and completed board certification (within five years of completion of training). An applicant’s Medical/Dental License or DEA License must never have been restricted. Also, an applicant must never have been excluded or precluded from anyFederal Program; Medicare/Medicaid or convicted of a felony. Finally, the Health System has exclusive contracts with certain specialties (Emergency Medicine, Anesthesia, Radiology, Pathology and Psychiatry.) An applicant cannot apply for privileges INDEPENDENT of one of these contracted groups.

If you are able to meet the above criteria, please complete the application.

______

Information Required From the Applicant: (If Applicable)

COPYof a government Issued Photo ID

(Driver’s License, Passport, Resident Visa Card, Naturalized Citizen Certificate)

List on your application ALL state licensure numbers (inactive & active)

Copy of DEA Certificate; copy of your NC License; a copy of Board Certification

Copy of Cover Sheet for current Professional Liability Insurance with limits of $1 million/$3 million

Copy of Cover Sheet for all insurance policies held during the past five years

Complete List with Contact Person, Telephone and Fax numbers for Internship, Residency, Fellowship and any Externship.

List of all professional affiliations/employers since completion of Medical/Dental School.

Three professional reference names, telephone number and fax numbers, which must be from colleagues within the same professional discipline who have observed the applicant’s clinical practice (letters will be sent out from the Medical Staff Office)

Certification information

Complete & Return the attached Medicare/Champus Acknowledgement Card

Complete & Return the attached Hospital Pharmacy Card

Complete the attached criminal history form

Documentation of TB skin test within six (6) months (if you are a TB skin test reactor, please furnish a copy of a negative chest x-ray)

ECFMG information along with a copy of your certificate

Current CV

MILITARY SERVICE: If you have served in the military a copy of one of the following is needed: Discharge Papers, Statement of Orders, or Duty History Form

Verification of information on the application form takes approximately six weeks. If difficulties are encountered in receiving the information, you will be asked to assist with the process to obtain the needed information. You also may be asked to provide specific information related to clinical privileges requested, i.e., number of procedures performed, verification of additional training, and education.

An interview may be requested to clarify information obtained during the verification process. You will be notified if this is necessary. Additional references may also be requested.

Following receipt of all required information, your application will be reviewed by the appropriate Department Chair, Credentials Committee, Medical Executive Committee, and the Board of Trustees which takes approximately an additional two weeks for a total of 60 days for the entire credentialing process.

To receive an application packet, please contact:

Geraldine Mulcahy, CPCS Credential Specialist

Phone: 336-878-6082, Fax: 336-878-6707

Email:.

Leslie Collins, Credential Specialist

Phone: 336-878-6435, Fax: 336-878-6707

Email:

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