Date *

Application Assistant Information

Name of person who might help applicant fill out portions of the application (ie: office manager, locum contact)

Phone

Email *

Applicant Information

Application is for *

First Name (as it appears/will appear on your professional license) *

Middle Initial

Last Name (as it appears/will appear on your professional license) *

Is this provider currently privileged within WellSpan Health or an employee of WellSpan Physician Group? *

Date of Birth *

Last 4 digits of provider's SSN *

CAQH Number Providing this information may expedite processing

Employee number

NPI

Pennsylvania License (You must complete one of these fields)

License # in Pennsylvania

Submitted Pennsylvania license application on

Title *

Primary Supervising/Collaborative Physician (PA/CRNP/CNM Only)

Primary Supervising/Collaborative Physician (PA/CRNP/CNM Only) *

Substitute Supervising/Collaborative Physician)

Substitute Supervising/Collaborative Physician) *

New Graduate?

Specialty *

Other, if specialty not shown

Provider Information

Street Address *

State *

Phone (Home)

Unique Email for the Provider *

City *

Zip Code *

Phone (Cell) *

Applicant's communication preference *

Practice Information

Primary Practice Name *

Primary Practice Address *

Please use 1000 characters or less

1000

Office Manager or Best Contact Name *

Office Manager or Best Contact Phone *

Office Manager or Best Contact Email *

Additional Details

Is the applicant currently practicing within a 50-mile radius of a WellSpan health facility?

Estimated Office Start Date

Estimated Hospital Start Date

Start date must be at least 90 days from the submission of this form and must be either the 2nd or 4th Monday of the month.
If start date is desired less than 90 days, please contact wellspanmedicalstaffservices@wellspan.org

Which facility/entity are you requesting? *

Apple Hill Surgery Center
Chambersburg Hospital
Cumberland Valley Health Network
Ephrata Community Hospital
Gettysburg Hospital
Good Samaritan Hospital
Philhaven
Roy Himelfarb Surgery Center
South Central Preferred
Waynesboro Hospital
WellSpan Chambersburg Endoscopy Center
WellSpan Health and Surgery Center
WellSpan Medical Group
WellSpan Surgery and Rehabilitation Hospital
WellSpan Surgical Center
WellSpan Surgical Center Lebanon
York Hospital

Explanation of credentialing request/Please list any special circumstances

Please use 1000 characters or less

1000

Captcha *