Get Oh Mount Carmel Health System Trinity Health (cpi) Application Request Form 2019-2025

Completing the OH Mount Carmel Health System Trinity Health (CPI) Application Request Form online is a straightforward process that will help streamline your application. This guide provides a clear and comprehensive overview of each section and field of the form, ensuring that users can navigate it with confidence.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the required fields indicated with an asterisk. Start with the practitioner's name, including first, middle, and last names, followed by the degree. Choose from the options: MD, DO, DPM, DDS, CRNA, NP, PA, PhD, or specify another degree if applicable.
3. Enter the date of birth in the mm/dd/yyyy format and provide the practitioner's email address.
4. Indicate if the applicant is still in residency and whether the Physician or APP Portal should be launched (for MSO use only).
5. Answer whether the practitioner is board certified and fill in the anticipated graduation date if applicable.
6. Provide information about the anticipated start date and if the practitioner will be contracted or employed by the hospital. Also, specify if they will be a locum tenens provider.
7. Fill in the credentialing contact information, including contact name, title, and email address. Include any additional comments if necessary.
8. Complete the practitioner office information. Indicate if joining an established practice, provide the office name, and fill in the office address along with the phone and fax numbers.
9. Specify the state where the applicant will be applying for licensure. If the practitioner does not possess a license, indicate whether an application for full licensure has been submitted.
10. Select the clinical privileges needed by checking all applicable options. Ensure to provide the CAQH number and confirm if it has been updated within the last 120 days.
11. Indicate to which facilities the practitioner is applying by checking the appropriate privilege forms located on page 2 of the document.
12. After completing all sections and fields, review the form for accuracy. Save changes, download, print, or share the form as needed.

Complete your application online today to ensure a smooth submission process.