Get Codhcoipascmc Membership Request Form - Central Oregon Bb

Filling out the Codhcoipascmc Membership Request Form is essential for obtaining membership and privileges within the Central Oregon Credentialing System. This guide provides clear, step-by-step instructions for successfully completing the form online, ensuring that users can navigate the process with ease.

Follow the steps to complete your membership request form.

1. Click the ‘Get Form’ button to obtain the form and open it in an editor.
2. Provide your personal information. Fill in your full legal name, expected arrival date, and indicate if you request privileges. If applicable, provide your Central Oregon or Columbia Gorge home address along with your contact information.
3. Fill out the practice information section. Indicate whether you plan to establish practice near your admitting facility. Answer the questions regarding your practice type and whether you accept new patients.
4. Select the membership categories you are applying for. Check the appropriate boxes for the Central Oregon Independent Practice Association and any relevant hospitals where you wish to hold privileges.
5. Attach required documentation as outlined. Include items like your intended practice plan statement, government-issued photo ID, CME certificates, and verification of board eligibility.
6. Complete the miscellaneous questions about your current status and any Medicare or Medicaid conditions of participation.
7. Complete the attestation, authorization, and release statements. Ensure you sign and date these sections to validate your application.
8. After completing all sections, review your responses for accuracy. Save your changes, and you may choose to download, print, or share the completed form as needed.

Complete your Codhcoipascmc Membership Request Form online today!