601 North Elm Street
P.O. Box HP-5
High Point, NC 27261
(336) 878-6000
www.highpointregional.com
Date: ______
Dear Applicant:
Enclosed are the necessary forms for application to the Allied Health Staff at High Point Regional. Also enclosed please find a current copy of our Medical Staff Bylaws, Rules and Regulations.
Each application has the obligation to assist with obtaining information necessary to complete his/her application. The health System’s credentialing policy requites primary source verification of references. The application is considered complete when the required information has been received and verified by the Medical Staff Office.
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Information Required From the Applicant: (If Applicable)
¨ COPY of 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 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
¨ Copy of College Degree / Special Training / On-the-Job Training
¨ Review of enclosed Orientation Manual and completion of Post-Test*
¨ List of all professional affiliations / employers for the last 5 years
¨ Three professional references, along with telephone and fax numbers, which must be from collegues within the same professional discipline who have observed the applicants clinical practice (letters will be sent out from the Medical Staff Office)
¨ Certification Information
¨ 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)
¨ Documentation of current seasonal flu vaccine (if applying during peak months)
¨ Urine Drug Screening (this test must screen for methamphetamines, amphetamines, cocaine, opiates and marijuana (THC)) – confidential results are to be faxed to the Medical Staff Office (336-878-6707 or 336-878-6248) from the healthcare provider / facility who administered the test**
¨ Current CV
¨ Signature of Sponsor
¨ 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
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. After the completed application is received, the entire credentialing process takes approximately 60 days.
Please take the time to make sure your application is as thorough and accurate as possible.
In the event you have any questions while completing your application or any issues you would like to discuss, please feel free to contact:
Leslie Tim, Credential Specialist
Phone: 336-878-6435, Fax: 336-878-6707
Email:
Brandi Hulin, RHIT, Credential Specialist
Phone: 336-878-6082, Fax: 336-878-6707
Email:
Sincerely,
J. Keith Miller, M.D.
Chairman of Credentials Committee
Enclosures
*Please complete Post-Test and return with application
**If your employer has required the equivalent drug screen, a copy on letterhead faxed from the medical office (employer) would be acceptable
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