PHSOR Application Request Form - New Applicant
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PHSOR Application Request for New Applicants
Full name
*
Include first, middle and last name.
Professional title
*
Example: MD/DO, ANP, PA-C, etc.
Best contact number
*
Use the format (999) 999-9999 or (999)999-9999.
Email address
*
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.
Birthdate (mm/dd/yyyy)
*
This information is used for password setup.
Anticipated hospital practice start date
*
Use the format (mm/dd/yyyy).
Select all facilities where you intend to practice
*
Providence Hood River Memorial Hospital
Providence Medford Medical Center
Providence Milwaukie Hospital
Providence Newberg Medical Center
Providence Portland Medical Center
Providence Seaside Hospital
Providence St Vincent Medical Center
Providence Willamette Falls Medical Center
Briefly describe the reason for your interest in applying to PHSOR Professional Staff
*
Clearly indicate your intended practice and desired privileges.
Briefly describe your practice specialty
*
Are you currently Board Certified?
*
Yes
No
No, but I intend to complete certification within five years of training completion
Credentialing contact first and last name
Credentialing contact email address
Has this individual been authorized to be copied on credentialing communications and assist with application materials?
Yes
No
If "no," whom should we include?
Credentialing contact phone number
Use the format (999) 999-9999 or (999)999-9999.
Credentialing contact fax number
Use the format (999) 999-9999 or (999)999-9999.
Primary office location name
Primary office location address
Primary office location phone number
Use the format (999) 999-9999 or (999)999-9999.
Primary office location fax number
Use the format (999) 999-9999 or (999)999-9999.
Submit your current CV or resume
Once you’ve submitted this form, please send your CV or resume to
CredentialingOffice@providence.org
.
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