Provider Fees

Practitioner Application Fees

Payment Form
Date*

MonthDayYear
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

Total

$0.00

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