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MedStaff Requests
DATE:
4/24/2024
Banner Health
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
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
Effective 8/7/2020 - 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
Sedgwick County Memorial Hospital (Contract)
Sterling Regional MedCenter
Wray Community District Hospital (Contract)
Yuma District Hospital (Contract)
Other States
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)
Medical Staff
Allied Health
APP
Community Based
Locum Tenens
Telemedicine
(Please check one)
* Required
Practice Plans
Anticipated Start Date for Privileges
Joining a group
Individual practice
Banner employed
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
* Required
City
* Required
State
* Required
Zip
* Required
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
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
E-Mail Address (application will be sent to this e-mail address)
* Required
Please enter a valid email address
Group Name
* Required
Covering Physician(s) (or sponsoring physician if Allied Health)
* Required
Date of Birth
* Required
Please enter a valid date in the form MM/DD/YYYY
Social Security #
* Required
Enter a SSN w/dashes
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
Certified
Qualified
Not Certified
* Required
(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)
* Required
City
State
Zip
* Required
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Graduation Date (mm/dd/yyyy)
* Required
Please enter a valid date in the form mm/dd/yyyy
Degree Earned
* Required
Post-Grad Training
Internship
Specialty
Facility
City
State
Zip
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Dates Attended:
From
Please enter a valid date in the form MM/DD/YYYY
To
Please enter a valid date in the form MM/DD/YYYY
Residency
Specialty
Facility
City
State
Zip
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Dates Attended:
From
Please enter a valid date in the form MM/DD/YYYY
To
Please enter a valid date in the form MM/DD/YYYY
Fellowship
Specialty
Facility
City
State
Zip
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Dates Attended:
From
Please enter a valid date in the form MM/DD/YYYY
To
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