Delegation of Credentialing Form

Provider Information

Provider Name

First Last

Phone

Credentialing Agency Information

Credentialing

I will perform my own credentialing

I authorize MPR to share my credentialing information with the following individual. The following individual shall be designated as my credentialing agent. I understand that the credentialing agent will be able to access, modify, and submit information through the MPR Online Application for clinical privileges and/or membership. I also authorize the following individual to sign on my behalf clinical privilege and membership documents, disclosures, authorizations, and any other type of document submitted for the completion of the MPR Online Application. This includes the use of my electronic signature.

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax Number

Acknowledgement and Agreement

Provider Signature