Medical Staff Forms

The following documents are utilized for initial appointment and/or reappointment to the Medical Staff of Hendrick Medical Center. Initial applicants must return all of the documents. Reappointment applicants only need to return the documents indicated by the asterisk.

Application Cover Letter- Please read this letter and utilize the included check list to ensure you are returning all of the required application documents.

Tips for Expediting Your Application – This document contains tips on what you can do to expedite the processing of your application.

* Texas Standardized Credentialing Application – This document is located on the Texas Department of Insurance website. To ensure that you do not lose data you must save the document to your computer prior to inputting pertinent information.

Initial Application Addendum - This addendum must be utilized by all initial applicants. It contains information not included on the Texas Standardized Credentialing Application that Hendrick Medical Center is required to obtain. Some of the questions may seem redundant but they are different.

*Reappointment Addendum - This addendum must be utilized by practitioners who are already on staff and are requesting reappointment. It contains information not included on the Texas Standardized Credentialing Application that Hendrick Medical Center is required to obtain. Some of the questions may seem redundant but they are different.

* Clinical Privilege Request Forms – You must contact the Medical Staff Services to obtain these documents.

* Physician Profile/Case List – The information outlined in this document must be provided by all initial applicants and all Affiliate reappointment applicants. It is utilized to determine current competence.

Medicare/Medicaid Attestation – This document is required upon initial application as mandated by federal regulations.

Credentials Notification Acknowledgement - This document defines for the applicant the various actions that must be reported to the Medical Staff Credentials Committee within fifteen (10) calendar days.

Apollo Access Agreement- This license agreement for access to Hendrick Information Network is required upon initial application.

New Physician Orientation Modules - This link provides access to orientation modules to be completed as part of the initial application process.

* Physician Re-credentialing Education - This link provides access to education modules to be completed as part of the reappointment process.

* These documents are required for reappointment.

Please print and complete each of these documents and return them to Medical Staff Services. If you have any questions, please contact Medical Staff Services at 325-670-2932.