A background check is required for all new applicants. An authorization and consent release form is included for your completion and signature. Upon receipt we will screen it. If all standards are met, your application will then be processed.
Please note: An incomplete application will be returned to you and will delay completion of the credentialing process. Any gaps in professional training or practice must be explained. A complete application is defined as an application on which every item is addressed. Every item must be addressed. Non-applicable areas should be indicated with the statement, “not applicable.” Do not write “see CV”.
The following items MUST BE RETURNED in order to process your application:
- Current curriculum vitae (CV).
- A copy of your current professional liability insurance fact sheet that shows your name, expiration dates and limits of at least $500,000/$1,000,000 in coverage.
- Check for $350 made payable to the Saint Francis Medical Staff (non-refundable application processing fee).
- A recent personal photograph.
- ACGME professional competency evaluation if recently completed residency/fellowship training.
- Physicians who are in active practice please provide quality information/data regarding your hospital practice at all institutions where currently appointed to the medical staff.
- Submit a case log/procedure list from the last two years for privileges you are requesting at Saint Francis Hospital. This list must be validated by the institution of practice or by your program director.
- Physicians who have served in the military during or after your training please provide DD Form 214 and Commissioned Office Evaluation Report (OER).
The application process includes the completion of the following documents:
- Consent and Release Form – Authorizes a background check.
- Application for Appointment
- Malpractice Claim History Form – Applicant is required to furnish information about all malpractice claims during the previous five (5) years.
- Physician Acknowledgement Form – A Medicare Attestation is required by the Medicare Conditions of Participation for Hospitals.
- Confidentiality Agreement—Physicians
- Environment of Care and Emergency Management Preparedness
- Bloodborne Pathogens
- Vaccine/Titer/Disease History
- Professional Staff Attestation and Consent Form
- Qualifications for Medical Staff Categories
The application must be received by the medical staff office within 30 days of the date it was signed by the applicant. All other required signatures must be signed within 30 days of receipt by the medical staff office.
Processing of your application is dependent on our receipt of the required documents from various sources. We make every effort to process expediently but can only complete the process when all documents are in place.
If you have any questions, please feel free to call the medical staff office at 918-494-1401. We appreciate your interest in Saint Francis Hospital and look forward to receiving your application.