Provider Fees

Practitioner Application Fees

Payment Form
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Email
example@example.com
Name of Practitioner:

PrefixFirst NameMiddle NameLast NameSuffix

Fee Type (All fees are Non-Refundable)

Initial Application Medical Staff (MD,DO, DPM, PhD, PsyD)

$750.00

Initial Application Allied Health Practitioner (PA/APRN/CRNA/CNM/RNFA)

$375.00

Reappointment Medical Staff (MD, DO, DPM, PhD, PsyD)

$450.00

Reappointment Allied Health Practitioner (PA/APRN/CRNA/CNM/RNFA)

$225.00

Expedited Application (An Additional)

If you are requesting the credentials file completion in less than 45 days. Exception - Emergency Privileges due to the life and death of the patient per Medical Staff Bylaws.

$750.00

Medical Record Fine

ONLY if you received notice from Health Information Management (HIM) for fines associated with delinquent medical records.

$100.00 Quantity

Total

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

Practitioner Application Fees

Fee Type (All fees are Non-Refundable)*

Fee Type (All fees are Non-Refundable)