Application Forms
Medical Staff (Doctor, Dentist, & CNM) Application
When forwarding your application to the medical staff office, the following items must also be returned:
Clinical Affiliate Staff Application
When forwarding your application to the medical staff office, the following items must also be returned:
- A copy of New York State license, professional certificate, registration
- A copy of D.E.A. registration certificate, if applicable
- A copy of professional malpractice insurance coverage (minimum $ 1 million / $ 3 million)
- A completed History and Physical Examination Form (pdf)
- A copy of 4NP Practice Protocol Form, if applicable
- A copy of certificate of completion of required training in infection control, if applicable
- A completed CME Form (pdf) listing continuing medical education hours within the last year
- Confidentiality Statement (pdf)
- COBRA Attest Card (pdf)
- Delineation of Privilege Form
- A valid picture ID from state, federal agency will be needed for on-site verification (e.g., drivers license or passport)
- National Provider Identifier (NPI) notification letter
Privilege Forms
Medical Staff Delineation of Privilege Forms
Required Education / In-services
Resources