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REQUEST FOR MEMBERSHIP AND CLINICAL PRIVILEGES
*Applicant Printed Name: _________________________________________________________________________
*Denotes required fields
(Last)
(First)
(M.I)
(Degree)
Maiden Name (Alias): ____________________________________________________________________________
(Last)
(First)
*DOB: ________________________ *SSN____________________________ Sex:
Male
Female
*Applicant Email: ________________________________________________________________________________
This email will be used for the online application; all correspondence regarding membership will be sent to this
email. Please add IU Health to your safe sender list and check junk/spam if you have not received the application
within 7 business days of your request.
Credentialing Contact
*Credentialing Contact Name: _________________________________________________________________________
* Cred. Contact Email: ________________________________________ *Cred. Contact Phone: _____________________
Applicant Home Address
*Street: _________________________________________________________________________________________
*City, State, Zip Code: _____________________________________________________________________________
*Phone #: _________________________________________
Applicant Work Address
Group/Practice Name: ______________________________________________________________________________
Street: __________________________________________________________________________________________
City, State, Zip Code: ______________________________________________________________________________
Phone #: ___________________________________________ Fax#: ________________________________________
Type of Membership and Clinical Privileges Requested:
*Anticipated Start Date:
Physician MD, DO, DDS
Allied Health Practitioner
Supv. Allied Health Practitioner
Moonlighter
Nurse Practitioner (NP)
Registered Nurse (RN)
Physician Assistant (PA-C)
Licensed Practical Nurse (LPN)
Certified Nurse Midwife (CNM)
Certified Surgical Tech (CST)
Clinical Nurse Specialist (CNS)
Social Worker
Podiatrist (DPM)
Radiology Tech
Psychologist (PhD)
Other: __________________
Cert. Reg. Nurse Anesthetists (CRNA)
Membership is requested for the following facility(ies):
IU Health - Arnett Hospital
IU Health - Ball Memorial Hospital
IU Health - Methodist/IU/Riley/Saxony/Morgan
IU Health - North Medical Center
IU Health - West Medical Center
IU Health - Tipton Hospital
IU Health - Bedford
IU Health - Bloomington
IU Health - Paoli
Glen Lehman Endoscopy Suite Indiana
Ball Outpatient Surgery Center
Endoscopy Center, LLC
Saxony Surgery Center, LLC
Senate Street Surgery Center, LLC
Eagle Highlands Surgery Center, LLC
Beltway Surgery Center, LLC Meridian
South Surgery Center
Riley Outpatient Surgery Center (ROC)
Southern Indiana Surgery Center
Indiana Hand to Shoulder Center
Multi-Specialty Surgery Center, LLC
IU Health has adopted an automated application to streamline its membership process. As part of the application process you
will be required to fill out and attest to an online application along with several required online forms available through a
personal Practitioner Home Page (PHP). In addition, you will be asked to upload required identification documents through the
PHP. The link to your personal Practitioner Home Page will be sent to the email on file (listed above). A separate email with
your password will follow.
After you receive the information regarding your Practitioner Home Page, the following documentation will be required as part
of the online application process to determine qualification for membership and clinical privileges requested:
PHYSICIANS
1.
Initial Online Application
2.
Curriculum Vitae
3.
Copy of current licensure to practice in the State of Indiana. If not currently licensed, documentation that application has been
submitted to the Health Professional Licensing Agency.
4.
Copy of current State of Indiana Controlled Substance Registration (CSR) or documentation that application has been
submitted to the Health Professional Licensing Agency.
5.
Copy of current Federal DEA. If you do not prescribe controlled substances, please submit a letter of explanation.
6.
Copy of current professional liability insurance or documentation that insurance has been applied for.
7.
Documentation of board certification or board eligibility status.
ALLIED HEALTH
1.
AHP Initial Application
2.
Curriculum Vitae
3.
Copy of licensure to practice in the State of Indiana. If not currently licensed, documentation that application has been
submitted to the Health Professional Licensing Agency.
4.
Copy of current State of Indiana Controlled Substance Registration (CSR) or documentation that application has been
submitted to the Health Professional Licensing Agency.
5.
Copy of current Federal DEA if applicable.
6.
Copy of current professional liability insurance or documentation that insurance has been applied for.
7.
Documentation of certification or board eligibility status if applicable.
8.
Copy of Collaborative Practice Agreement, if applicable.
9.
BLS, ACLS, PALS, NALS certification as indicated by privileges requested (BLS is required at a minimum).
SUPERVISED ALLIED HEALTH
1.
Supervised Allied Health Online Application
2.
Current Job Description
3.
Sponsor Letter from physician employer/supervisor
4.
Copy of current professional liability insurance or documentation that insurance has been applied for.
5.
Copy of current licensure or certification to practice as a Supervised Allied Health Practitioner.
6.
BLS Certification
Signature: ______________________________________________ Date: ___________________________________
*IU Health, IU Health North, and IU Health West have entered into exclusive arrangements with the following physician
groups to provide clinical services at IU Health facilities in the areas of anesthesia, pathology, radiology and emergency
medicine. In order to practice at an IU Health facility in these clinical areas, you will need to be a member of the
appropriate group:
Anesthesia: Anesthesia Consultants of Indianapolis, LLC (Adult only at North) and
IU Anesthesiology Associates, LLC (Pediatric only at North)
(Excluding Pain Management at all facilities)
Pathology: Indiana Pathology Institute, P.C.
Radiology: Indiana Radiology Partners, Inc. (Diagnostic only at North)
Emergency Department: Emergency Medical Group Inc.
*IU Health Bedford, IU Health Bloomington, IU Health Paoli, and Southern Indiana Surgery Center have entered into
exclusive arrangements with the following physician groups to provide clinical services at IU Health facilities in the areas
of anesthesia, pathology, radiology, and emergency medicine. In order to practice at an IU Health facility in these clinical
areas, you will need to be a member of the appropriate group:
Anesthesia: Bloomington Anesthesiologists, PC (Bloomington & Southern Indiana Surgery Center)
(Excluding Pain Management)
Pathology: Southern Indiana Pathologists (Bloomington & Paoli)
Radiology: Southern Indiana Radiological Associates & NightShift Radiology (Bloomington & Paoli) and
Indiana Radiology Partners (Bedford)
Emergency Department: IU Health Southern Indiana Physicians (Bedford, Bloomington, & Paoli)
*Please contact the appropriate facility Medical Staff Office if further clarification is needed
PLEASE FAX THIS COMPLETED FORM TO (317) 968-1060
OR EMAIL TO: [email protected]
REQUEST FOR PRIVILEGES
Department/Service Privileges are Requested (please check for each facility at which privileges are being requested):
IU Health Academic Health Center (Methodist/IU/Riley/Saxony/Morgan)
Anesthesia
Nephrology
Cardiology
Neurology
Cardiovascular Surgery
Neurosurgery
Dermatology
Obstetrics & Gynecology
Emergency Medicine*
Ophthalmology
Family Practice
Oral/Maxillofacial & Dentistry
Gastroenterology
Orthopaedics
Hematology/Oncology
Otolaryngology/Head & Neck
Infectious Disease
Pathology*
Internal Medicine
Pediatrics, General
Medical & Molecular Genetics
Pediatrics, Specialty
ALLIED HEALTH
Certified Nurse Midwife
Physician Assistant
Nurse Practitioner
Podiatry
IU Health West Hospital
Anesthesia
Pain Management
Cardiology
Emergency Medicine*
Family Practice
Gastroenterology
General Surgery
Colon & Rectal
Hematology/Oncology
Internal Medicine
Geriatrics
Infectious Disease
Rheumatology
ALLIED HEALTH
Nurse Practitioner/CNS
IU Health North Hospital
Anesthesia*
Family Medicine
Medicine
Cardiology
Dermatology
Emergency Medicine*
Gastroenterology
Hematology/Oncology
Internal Medicine
Nephrology
Neurology
Physical Medicine & Rehab
Psychiatry
Pulmonary/Critical Care
ALLIED HEALTH
Nurse Practitioner/CNS
Nephrology
Neurology
Neurosurgery
Obstetrics & Gynecology
GYN & Urogynecology
Gynecological Oncology
Maternal Fetal Medicine
Reproductive Endocrinology
Ophthalmology
Oral/Maxillofacial & Dentistry
Orthopaedics
Otolaryngology
Pathology*
Physician Assistant
Psychologist
Pediatrics
Neonatology
Pediatric Cardiology
Pediatric Pulmonology
Physical Medicine & Rehab
Plastic Surgery
Psychiatry
Pulmonary/Critical Care
Radiation Oncology
Radiology*
Urology
Vascular Surgery
Podiatry
Obstetrics & Gynecology
Pathology*
Pediatrics
Adolescent Medicine
Cardiology
Community Pediatrics
Critical Care/Pulmonology
Developmental Pediatrics
Endocrinology
Gastroenterology
Hematology/Oncology
Neonatology
Neurology
Radiology*
Physician Assistant
Pediatric Surgery
Peripheral Vascular Surg
Physical Medicine & Rehab
Plastic Surgery
Psychiatry
Pulmonary/Critical Care
Radiation Oncology
Radiology*
Surgery (General, Trauma, Transplant)
Urology
Vascular Surgery
Podiatry
Radiation Oncology
Surgery
Cardiovascular Surgery
General Surgery
Neurosurgery
Ophthalmology
Oral/Madillofacial & Dentistry
Orthopaedic Surgery
Otolaryngology
Pediatric Surgery
Plastic Surgery
Urology
Vascular Surgery
Psychologist
IU Health Arnett Hospital
Anesthesia
Allergy & Immunology
Cardiology
Cardiovascular Surgery
Critical Care
Dentistry & Oral Max Surgery
Dermatology
Emergency Medicine
Endocrinology
Family Medicine
Gastroenterology
General Surgery
Hand Surgery
Hematology/Oncology
Hospitalist
ALLIED HEALTH
Certified Nurse Specialist
Nurse Practitioner - Adult
Nurse Practitioner - Family Med
IU Health Ball Memorial Hospital
Anesthesiology
Cardiology
Critical Care
Dental
Dermatology
Emergency Medicine
Emergency Medicine (Med ED)+
Family Medicine
Family Medicine Amb Teaching
Gastroenterology
General Surgery
ALLIED HEALTH
Certified Nurse Midwife
Nurse Practitioner/CNS
IU Health Tipton Hospital
Anesthesiology
Cardiology
Dental
Dermatology
Emergency Medicine
Endocrinology
Family Practice
Gastroenterology
General Surgery
Infectious Disease
Internal Medicine
ALLIED HEALTH
Nurse Practitioner/CNS
Infectious Disease
Internal Medicine
Neonatology
Nephrology
Neurology
Obstetrics & Gynecology
Occupational Medicine
Ophthalmology
Orthopaedics
Otolaryngology
Pain Management
Pathology
Pediatric Cardiology
Pediatric Surgery
Pediatric Urology
Pediatrics
Physical Medicine & Rehab
Plastic Surgery
Podiatry
Psychiatry
Pulmonary Medicine
Radiation Oncology
Radiology
Rheumatology
Thoracic Surgery
Urgent Care
Urology
Vascular Surgery
Nurse Practitioner - Neonatology
Nurse Practitioner - Pediatrics
Physician Assistant
Physician Assistant - Emergency
Psychologist
Other: ___________________
Medicine
Medicine Ambulatory Teaching
Medicine (Med Ed)+
Nephrology
Neurology
Neurology-Remote Monitoring
Neurosurgery
Obstetrics & Gynecology
Ophthalmology
Orthopaedic Surgery
Otolaryngology
Pathology & Laboratory
Pediatrics
Physical Medicine
Podiatry
Psychiatry
Psychiatry (Med Ed)+
Pulmonary Disease
Radiology
Urology
Physician Assistant
Psychologist
Radiology Technologist
Social Worker
Neurology
Obstetrics/Gynecology
Oncology
Ophthalmology
Oral Surgery
Orthopaedic Surgery
Otolaryngology
Pathology
Pediatrics
Plastic Surgery
Podiatry
Psychiatry
Pulmonary Medicine
Radiology
Rheumatology
Sleep Study Interpretation
Urology
Vascular Surgery
Physician Assistant
Psychologist
Surgery Center Privileges
Ball Outpatient Surgery Center, LLC
Meridian South Surgery Center
Beltway Surgery Centers, LLC Eagle
Riley Outpatient Surgery Center (ROC)
Highland Surgery Center, LLC Glen
Saxony Surgery Center, LLC
Lehman Endoscopy Suite, LLC Indiana
Senate Street Surgery Center, LLC
Endoscopy Centers, LLC
Multi-specialty Surgery Center
Indiana Hand to Shoulder Center
Anesthesia
Dermatology
Gastroenterology
Neurology
Neurosurgery
Obstetrics & Gynecology
Ophthalmology
Oral & Maxillofacial Surgery
Orthopaedic Surgery
Otolaryngology/Head & Neck
Pediatric Surgery
Physical Medicine & Rehab
IU Health Bedford Hospital
Emergency Care*
Pediatrics
Medicine
Psychiatry
Allergy
Pulmonology
Cardiology
Radiology
Dermatology
Surgery
Endocrinology
Anesthesia
Family Medicine
Pain Medicine
Gastroenterology
Dental/Oral Surgery
Hematology
General Surgery
Internal Medicine
Ophthalmology
Medical Oncology
Otolaryngology
Nephrology
Orthopaedics
Neurology
Pathology
Occupational Medicine
Plastic Surgery
ALLIED HEALTH/ADVANCED PRACTICE PROVIDERS
CRNA
Nurse Practitioner/CNS
Physician Assistant
IU Health Bloomington Hospital
Anesthesia*
Physical Med & Rehab
Pain Medicine
Pulmonary
Emergency Medicine*
Sports Medicine
Family Medicine
Obstetrics & Gynecology
Medicine
Palliative Medicine
Allergy/Immunology
Pathology*
Cardiology
Pediatrics
Critical Care
Psychiatry
Dermatology
Refer & Follow
Endocrinology
Radiology*
Gastroenterology
Interventional
Hematology/Oncology
Radiation/Oncology
Internal Medicine
Surgery
Infectious Disease
Cardiothoracic
Nephrology
Cardiovascular Surgery
Neurology
DaVinci
ALLIED HEALTH/ADVANCED PRACTICE PROVIDERS
Certified Nurse Midwife
Physician Assistant
Nurse Practitioner/CNS
Other:
Plastic Surgery
Podiatry
Surgery
Urology
Vascular Surgery
Podiatry
Thoracic
Urology
Vascular
Telemedicine
Neurology
Peds Cardiology
Peds Neurology
Peds Psychiatry
Psychiatry
Radiology
Sleep Disorders
Psychologist
Dentistry/Peds Dentistry
General
Neurological
Ophthalmology
Oral/Maxillofacial
Orthopaedic
Otolaryngology
Peds Surgery
Plastic Surgery
Podiatry
Urology
Vascular
Urgent Care
Psychologist
IU Health Paoli Hospital
Anesthesiology
Oncology/Hematology
Emergency Medicine*
Ophthalmology
Medicine
Orthopaedic
Cardiology
Palliative Medicine
Dermatology
Pain Management
Family Medicine
Pathology*
Gastroenterology
Radiology*
Internal Medicine
Sleep Medicine
Obstetrics & Gynecology
ALLIED HEALTH/ADVANCED PRACTICE PROVIDERS
Certified Nurse Midwife
Nurse Practitioner/CNS
CRNA
Other:
Southern Indiana Surgery Center
Anesthesiology*
Oncology
Cardiovascular Surgery
Ophthalmology
Gastroenterology
Oral/Maxillofacial
General Surgery
Orthopaedic
Gynecology
Otolaryngology
Laser
Pain Medicine
Lithotripsy
Physical Medicine & Rehab
Neuro Surgery
Plastic
ALLIED HEALTH/ADVANCED PRACTICE PROVIDERS
Nurse Practitioner/CNS
RN-Lithotripsy
Physician Assistant
Other:
Surgery
General Surgery
Otolaryngology
Plastic
Podiatry
Urology
Telemedicine
Physician Assistant
Podiatry
Psychiatry
Radiology
Urology