REQUEST TO SEND APPLICATION PAGE | Medical Provider Resources

Applicant Legal Name*

First Middle Last

Date Of Birth*

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

Requesting Clinical Privileges In Speciality(ies) (separate with commas)*

Group/Practice Info

Primary Employer/Group/Practice*

Group/Practice Address*

Street Address Address Line 2 City State ZIP Code

Group/Practice Phone

Group/Practice Fax

Group/Practice Email*

Credentialing Contact Info

Credentialing Contact/Office Manager*

Credentialing Contact Address*

Street Address Address Line 2 City State ZIP Code

Credentialing Contact Phone

Credentialing Contact Fax

Credentialing Contact Email*

Provider Information

Provider Home Address*

Street Address Address Line 2 City State ZIP Code

Provider Phone

Provider Fax

Provider Email*

Please Send Application To:*

Group/Practice
Credentialing Contact
Home

Do you want this file expedited?*

Expedited
Non-expedited

Additional fee of $615 is required prior to expedited processing. Please submit expedited fee to Katie Degenhardt, Expedited File Specialist, at katiedegenhardt@mprcred.com.

Anticipated date to begin practice.*

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?*