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DATE: 4/20/2014 Banner Health
In-Query Credentialing Services
Call toll free 1-855-877-1716

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)
Arizona













Colorado
















Other States
AlaskaKansasNevadaSouth Dakota
CaliforniaNebraskaNorth DakotaWyoming




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  
Telephone   Fax 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)  
Home Address
City State Zip
Home Telephone Home Fax Personal Email Address
Date of Birth Social Security #
Medical/Professional License # State
NPI #     NPI Password DEA #
Malpractice Ins. Carrier   Policy #
Name of Insured Amount of Coverage
Effective Date   Expiration Date  

Have you had or are there currently any pending claims/complaints filed against you within the last ten years?  

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

Medical School Attended (or Medical Training if Allied Health)   
Medical School Address
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) 392-2110 or emailed to cvoapplicationrequests@bannerhealth.com.