Get Fl Tgh Request For Medical Staff Application (pre-application) 2008-2025

This guide provides clear and supportive instructions on how to complete the FL TGH Request for Medical Staff Application (Pre-application) form online. By following these steps, users can ensure a smooth submission process.

Follow the steps to fill out the FL TGH request for medical staff application form online.

1. Click the ‘Get Form’ button to access the application form online. Ensure that you have a reliable internet connection before proceeding.
2. Today’s date: Enter the current date in the space provided at the top of the form, ensuring it is legible.
3. Full name: Type your full name as you wish it to appear, including professional designations such as MD, DO, DPM, or DDS.
4. Social security number: Carefully enter your social security number in the designated field.
5. Office address: Fill in your office address including the street, city, state, and zip code.
6. Contact information: Provide your office telephone number, fax number, and email address. Ensure your email is accurate for future correspondence.
7. Residence address: Enter your home address, including the street, city, state, and zip code.
8. Indicate the preferred address for correspondence by checking either 'Office' or 'Residence'.
9. Name of group: Include the name of your professional group, if applicable.
10. Residency/fellowship details: Fill in the year you completed your accredited residency or fellowship and any board certifications.
11. Licensing information: Provide your Florida medical license number, and if it is not available, indicate if you have applied for it.
12. Clinical specialty: Clearly indicate your clinical specialty and any additional privileges you wish to request.
13. Hospital usage: Explain your anticipated use of the facilities at Tampa General Hospital, including the percentages for your total practice and total hospital practice.
14. Office establishment: Indicate whether you plan to have an office near the hospital and provide the location if applicable.
15. Current appointments: Answer whether you are currently appointed to the medical staff of any other hospital and provide details if applicable.
16. Practice activity: Confirm if you have practiced in your field within the previous 24 months, or completed a residency/fellowship in the last 18 months.
17. Participation in Medicare/Medicaid: Indicate your participation status in Medicare and Medicaid, and provide relevant numbers.
18. Emergency call rotation: Agree to participate in the emergency call rotation and treat all patients referred to you regardless of their ability to pay.
19. Employment details: State whether you are employed by any other hospital or its affiliates.
20. Conflict of interest: Disclose any business interests that may pose a conflict of interest with Tampa General Hospital.
21. Document submission: Make sure to gather and attach the required documents and the $50 pre-application fee before mailing your completed form.
22. Final check: Review all entries for accuracy and clarity, and ensure you have signed and dated the application before submission.
23. Once completed, you can save your changes, download the form for your records, print it out, or share it as necessary.

Start filling out your FL TGH Request for Medical Staff Application online today!