Get Sponsoring Physician Statement - Banner Health

Filling out the Sponsoring Physician Statement is an important step in ensuring that patient care services are provided under qualified supervision. This guide will walk you through the process of completing the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. In the first field, enter the name of the applicant who is requesting permission to provide patient care services. Ensure this is accurate to avoid any processing delays.
3. Next, specify the position or title that the applicant is applying for. This should align with the scope of services they will be providing.
4. Review the statement regarding your familiarity with the applicant’s qualifications, character, and clinical competence. Be sure to only affirm this if you are confident in the applicant's abilities.
5. Sign in the designated area to indicate your agreement to supervise the applicant and assume responsibility for their actions within their outlined privileges.
6. Fill in the date when you are completing the form in the specified field.
7. If there are additional sponsoring physicians, indicate their names in the provided space. This is important for clarity on who will share responsibility.
8. Once all fields are filled, review the document to ensure accuracy. After confirming all information is correct, save your changes and download a copy for your records.
9. You can also print the form or share it with relevant parties as necessary.

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