PinnacleHealth Employed Allied Health Provider
Thank you for your interest in practicing at PinnacleHealth Hospitals. The following documents will be necessary to complete your Medical Staff Credentialing. Please note that these processes take at a minimum 2-3 months to complete.
To complete the additional required online forms as outlined below, please use the following link: http://www.pinnaclehealth.org/for-employees-and-professionals/for-medical-professionals/physician-and-practitioner-services/physician-and-allied-health-staff-applications
Please do not hesitate to contact me with any questions.
Heather Johnson, Manager of Physician & Practitioner Services
Office: 717-231-8302
Cell: 717-476-0893
Email:
Pennsylvania Standard Application
Pinnaclehealth supplemental application
CV IN MONTH/YEAR FORMAT (VERY IMPORTANT TO HAVE BEGINNING & ENDING MONTHS/YEAR ON CV)
WRITTEN EXPLANATION FOR “ANY” WORK GAP One month or greater (since matriculation from medical school)
DIPLOMA(S) (please include Bachelor, Master and/or Doctorates); official transcripts are acceptable if you don’t have a copy of your diploma)
SOCIAL SECURITY CARD
PA STATE Board of Medicine LICENSE https://www.mylicense.state.pa.us/
DEA (with PA address; may use practice location address) http://www.deadiversion.usdoj.gov/drugreg/process.htm
Driver’s License
BOARD CERTIFICATION – if applicable
MALPRACTICE FACE SHEET (and/or Current Certificate of Insurance) – These are available from the Risk
Management offices at your Current facility or educational institution
MALPRACTICE FACE SHEETS FOR THE PRIOR 5 YEARS – These are available from the Risk Management offices at your Current facility or educational institution
Privilege Form – if applicable
Procedure Logs – if applicable
BLS, ACLS, ALSO, PALS, ATLS, NALS and CPR Certificates ̶ if applicable
Marriage certificate if you have had a recent name change within the last 6 months
Attend onsite orientation – This will be schedule by Human Resources.
Photo taken at interview or emailed to us
Supervising/Collaborative Agreement – We need copies of what is submitted to the state and the formal approval from the state. If you need assistance with these agreements please do not hesitate to contact us.
Enrollment Materials
MEDICARE WELCOME LETTER (if already par with PA Medicare)
NPI CONFIRMATION EMAIL / WELCOME LETTER
NPPES USERNAME AND PASSWORD (if applicable) https://nppes.cms.hhs.gov/NPPES/Welcome.do- if you do not remember your Login and password you will need to contact the NPPES and reset.
CAQH account, username and password (if applicable) ̶ You will only have this if you are currently graduated and practicing at a Health
Care facility or organization. (The Enrollment Department/office typically has this information)
Provider Enrollment Forms/ Attestations – We ask that you sign, but do not date. We need these Documents mailed via US Postal or sent via FedEx
All documents can be completed and scanned to me via email, with the exception of the Provider Enrollment Forms/Attestations.