Initial Provider Credentialing Request

Thank you for your interest in applying to the medical staff at Virginia Mason Franciscan Health. Please provide this information for general purposes to initiate your privileging request.

Provider Credentialing Resources

Medical Staff Bylaws
Credentialing Policy

If you have any questions, please email Medical Staff Services or call (206) 341-0097.

Name (first and last): *

Email Address: *

Phone Number:

Organization:

Specialty:

Special Interest/Focus:

Anticipated Start Date at Virginia Mason Franciscan Health:

(mm/dd/yyyy)

Please provide a brief description of your primary clinical practice:

What is/will be the location of your primary clinical practice?

Will Virginia Mason Franciscan Health be your primary hospital affiliation?

If you answered No, which hospital will be your primary affiliation?

What approximate percentage of your practice will be at Virginia Mason Franciscan Health?

Consultations:

Admitting:

Procedures:

Surgeries:

Authentication *

* Required

Initial Provider Credentialing Request

Current Practice

What is your anticipated patient volume at Virginia Mason Franciscan Health?