Get Request An Application Here - Mary Washington Healthcare

Filling out the Request An Application Here form is a crucial step in seeking credentialing with Mary Washington Healthcare. This guide provides a clear and structured approach to completing the form online, ensuring a smooth application process for all users.

Follow the steps to successfully complete your application request.

1. Click the ‘Get Form’ button to download and open the application request form.
2. Enter the date of your request in the designated field. Make sure to use the format that is specified in the form.
3. Provide the applicant's full name in the appropriate section. If you are submitting the request on behalf of someone else, fill out the name of the person submitting the request as well.
4. Complete the personal information section by selecting the applicant's specialty and practice name. Indicate the type of practitioner by marking the appropriate box.
5. Specify if the applicant will be a solo practitioner by answering yes or no.
6. In the section for delivery method, select either email or postal mail. If selecting email, ensure you provide a valid email address. For postal delivery, include the full street address.
7. Provide a contact phone number where you can be reached for any follow-up questions.
8. Indicate the applicant's purpose for applying by selecting one of the options regarding MHS-related information.
9. If applicable, indicate whether the applicant is an MHS-employed or non-MHS employed practitioner and provide relevant dates if there are locum tenens.
10. For non-physicians, specify the type of employment or contract status and if they will be insured by MHS.
11. If the applicant has been on the medical staff of any MHS entities in the past, answer yes and provide the relevant time period.
12. Select all entities the applicant plans to apply to by checking each applicable box.
13. Once all fields are completed, review your form for accuracy. After verifying the information, click 'Print Form' to generate a copy.
14. You may fax the completed form to the Centralized Credentialing Services at the number provided.

Complete your Request An Application Here form online and ensure your application is submitted promptly.