Request to Send Application

For best results, please use Google Chrome

Applicant Legal Name
Last
First
Middle

Date of Birth (mm/dd/yyyy)

Professional Suffix (e.g. MD, PA, DDS, RN)

Requesting Clinical Privileges in Specialty(ies)

Primary Employer/Group/Practice
Group/Practice Address
City, State Zip Code

Credentialing Contact/Office Manager
Credentialing Contact Address
City, State Zip Code
Telephone
Fax
E-Mail

Provider Home Address
City, State Zip Code

Practitioner Email

Please Send Application To:
Group/PracticeCredentialing ContactHomeEmailed

Do you want this file expedited? (Additional fee of $595 is required prior to expedited processing. Please submit expedited fee to Katie Degenhardt, Expedited File Specialist, at katiedegenhardt@mprcred.com.)
ExpeditedNon-Expedited

Anticipated date to begin practice (mm/dd/yyyy)

Does the applicant have, or plan to establish, an office and live within a reasonable distance of the hospital(s)/health care entity to which you are applying to allow for continuous care for hospitalized patients?
YesNoN/A

Physician Applicant: Is the applicant board certified?
YesNoN/A

If no, is provider currently practicing as a locum tenens or telemedicine practitioner?
YesNoN/A

Non-Physician Practitioner Applicant: Have and maintain professional liability insurance?
YesNoN/A

Sponsoring Physician

Medical Societies:

Medical Society of Sedgwick County * NPP CREDENTIALING NOT APPLICABLE

Health Care Facilities:

Aesthetic and Plastic Surgery, LLC

Andover Ambulatory Surgery Center

Ascension Via Christi Hospital Manhattan, Inc.

Ascension Via Christi Hospitals Wichita, Inc.

Ascension Via Christi Hospital St. Teresa

Ascension Via Christi Rehabilitation Hospital, Inc

Ashland Hospital District #3

Aspen Mountain Medical Center

Center for Same Day Surgery

Cheyenne County Hospital

Citizens Medical Center Inc.

Clay County Medical Center

Cloud County Health Center

Coffey County Hospital

Coronado Surgical Recovery Suites

Cypress Surgery Center

Ellinwood District Hospital

Ellsworth County Medical Center

Endoscopic Services, PA

Fredonia Regional Hospital

Goodland Regional Medical Center

Greeley County Hospital

Greenwood County Hospital

HealthCore Clinic

Herington Municipal Hospital

Hunter Health Clinic

Jewell County Hospital

Kansas Heart Hospital

Kansas Medical Center

Kansas Spine & Specialty Hospital

Kansas Surgery and Recovery Center

Kearny County Hospital

Kiowa County Memorial Hospital

Lane County Hospital

Larksfield Place Retirement Community * NPP CREDENTIALING NOT APPLICABLE

Lincoln County Hospital

Lindsborg Community Hospital

MAO Leawood Surgery Center

Medicine Lodge Memorial Hospital

Midwest Surgery Center * NPP CREDENTIALING NOT APPLICABLE

Minneola District Hospital

Mitchell County Hospital

Newton Medical Center * NPP CREDENTIALING NOT APPLICABLE

Ottawa County Health Center

Phillips County Hospital

Plastic Surgery Center-Wichita

PrairieStar Health Center

Precision Surgery Center

Rawlins County Hospital

Ridgewood Surgery and Endoscopy Center

Rock Regional Hospital

Satanta District Hospital

Sheridan County Health Complex

Smith County Hospital

St. Anthony’s Senior Care Hospital - Olathe

St. Anthony’s Senior Care Hospital - Wichita

St. Luke’s South Ambulatory Surgery Center (ASC)

Summit Medical Center

Surgery Center at Lone Tree

Surgery Center of Kansas

Susan B Allen Memorial Hospital

Trego County Lemke Memorial Hospital

Wamego Health Center

Wesley Medical Center

Wichita County Health Center

*NON-PHYSICIAN PRACTITIONER CREDENTIALING NOT APPLICABLE

Additional Comments

Name of Requesting Individual

Email Address