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 MedStaff Requests  
DATE: 5/24/2018 Banner Health
In-Query Credentialing Services
Call toll free 1-855-877-1716
If you have not received a response to your Request for Initial Application submission after 10 days, you may contact
for a status update.

Request for Initial Application
(this request will be forwarded to the facilities you select below, to determine if you meet their criteria for membership and privileges. If you do meet the critera, the facility will approve you to receive an application.)
I am applying for privileges/membership to: (check all that apply)


Other States

ALL OF THE FOLLOWING INFORMATION IS REQUIRED. (if information is pending or not applicable, please indicate)
(Please check one)  
Practice Plans Anticipated Start Date
First Name   Middle Name Last Name   Degree  
Primary Office / Mailing Address  
City   State   Zip  
Office Telephone   Office Fax Applicant Cell Phone
E-Mail Address (application will be sent to this e-mail address)  

Group Name  
Covering Physician(s) (or sponsoring physician if Allied Health)  
Date of Birth Social Security #

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.  
NPI #    
Malpractice Ins. Carrier  
Amount of Coverage

Primary Specialty  
Specialty Board/Certification Status           (select at least one)
List Board Name  
Do you have any subspecialties? If so, please list:

Medical School Attended (or Medical Training if Allied Health)   
City State Zip
Graduation Date (mm/yy) Degree Earned

Post-Grad Training

Please forward a copy of your Curriculum Vitae (CV) to the CVO. It can be faxed to (970) 810-2110 or emailed to cvoapplicationrequests@bannerhealth.com.