Resignation from Providence Oregon Professional Staff  

 
 

This form is to be submitted by the practitioner only.

If you are wanting to relinquish at only one site, do not use this form. Instead, submit a status change request here.
   
 
*
Include first, middle and last name.
 
   
 

Example: MD/DO, ANP, PA-C, etc.
 
   
 

Use the format (999) 999-9999 or (999)999-9999.
 
   
 
*
The PHSOR Regional Credentialing Office communicates with PHSOR practitioners via email. Medical Staff Services communications, including confidential credentialing and privileging communications, will be sent to this email address.
 
   
 
*
We will remove your clinical privileges on this date.
 
   
 

 
   
 

 
   
 

 
   
 

Use the format (999) 999-9999 or (999)999-9999.
 
   
 

 
   
 

By clicking "submit," I am voluntarily resigning my Providence Health & Services membership.
   
 
 Submit