MedStaff Requests

Banner Health

Call toll free 1-855-877-1716

Date 11/21/2024

If you have not received a response to your Request for Initial Application submission after 10 days, you may contact CVOApplicationRequests@bannerhealth.com for a status update.

Request for Initial Application

This request will be evaluated to determine if you meet facility criteria for membership and privileges. If you do meet criteria, you will receive an application

This form is to request medical staff membership/privileges at a Banner facility. If you are interested in participating in the Banner Health Network, access this link: https://www.bannerhealthnetwork.com/providers/becomeanetworkprovider

If you are interested in applying for privileges/membership to Banner Surgery Centers, please email bsc.credentialing@atlashp.com

I am applying for privileges/membership to: (check all that apply)

Arizona

Banner Baywood Medical Center
Banner Behavioral Health Hospital-Scottsdale
Banner Boswell Medical Center
Banner Casa Grande Medical Center
Banner Del Webb Medical Center
Banner Desert Medical Center (Including Banner Children's at Desert)
Banner Estrella Medical Center
Banner Gateway Medical Ctr (including Banner MD Anderson Cancer Ctr)
Banner Goldfield Medical Center
Banner Heart Hospital
Banner Ironwood Medical Center
Banner Ocotillo Medical Center
Banner Page Hospital
Banner Payson Medical Center
Banner Thunderbird Medical Center (including Out Patient Surgery Department)
Banner University Medical Center Phoenix
Banner University Medical Center South
Banner University Medical Center Tucson

Colorado

Banner Ft Collins Medical Center
East Morgan County Hospital
McKee Medical Center
North Colorado Medical Center
Sterling Regional MedCenter

California

Banner Lassen Medical Center

Nevada

Banner Churchill Community Hospital

Nebraska

Ogallala Community Hospital

Wyoming

Community Hospital

Platte County Memorial Hospital

Washakie Medical Center

Wyoming Medical Center

All of the following information is required. (if information is pending or not applicable, please indicate)

(Please check one)

Medical Staff
Allied Health
APP
Community Based
Locum Tenens
Telemedicine

Required

Practice Plans

Joining a group
Individual practice
Banner employed

Anticipated Start Date for Privileges Please enter a valid date in the form mm/dd/yyyy

First Name Required

Middle Name

Last Name Required

Degree Required

Primary Office/Mailing Address related to your work at Banner - This must be accurate as it will be added to the database as primary office information.

Required

City Required

State Required

Zip Required

Office Telephone Required Please enter a valid Phone number

Office Fax Please enter a valid Fax number

Applicant Cell Phone Please enter a valid Cell number

Provider's Direct E-Mail Address (REQUIRED): (application link will be sent to this e-mail address) Required Please enter a valid email address

Admin E-Mail Address:(application link will also be sent to this address to assist in application completion) Required Please enter a valid email address

Group Name Required

Covering Physician(s) (or sponsoring physician if Allied Health)-must be provided for request to be considered.If hospital-based specialty or telemedicine enter N/A. Required

Social Security # Required Enter a SSN w/dashes

Date of Birth Required Please enter a valid date in the form MM/DD/YYYY

If you do not have a current license in the state where you are applying for privileges, indicate the date you applied to the licensing board.(mm/dd/yyyy)

Please enter a valid date in the form mm/dd/yyyy

NPI # Required Must be 10 digits

Malpractice Ins. Carrier Required

Amount of Coverage

Primary Specialty Required

Specialty Board/Certification Status (select at least one)

Certified Qualified Not Certified

Required

List Board Name

Do you have any subspecialties? If so, please list:

Medical School Attended (or Medical Training if Allied Health) Required

City Required

State

Zip

Graduation Date Required Please enter a valid date in the form mm/dd/yyyy

Degree Earned Required

Post-Grad Training

Internship

Specialty

Facility

City

State

Zip

Dates Attended Please enter a valid date in the form MM/DD/YYYY

Residency

Specialty

Facility

City

State

Zip

Dates Attended Please enter a valid date in the form MM/DD/YYYY

Fellowship

Specialty

Facility

City

State

Zip

Dates Attended Please enter a valid date in the form MM/DD/YYYY

Please upload your Curriculum Vitae (CV)

Please upload your Curriculum Vitae (CV) or forward your CV to the CVO at email CVOapplicationrequests@bannerhealth.com or fax (970) 810-2110.

Curriculum Vitae (CV) is Required to complete your request. Please forward your CV to the CVO at the email listed below.

CVOApplicationRequests@bannerhealth.com