Request for Application to Join Professional Staff

Please complete the following request form for Application for Professional Staff Membership/Allied Health Membership.

*Required

*Name

First:
Last:
Title(s)/Degree(s)

Practice Information:

* Street Address:
Address Line 2:
* City:
* State:
* Zip:
* Office Phone:
Office Fax:
* Email:
* Practicing/Employed By:
* Clinical Specialty:

* How would you like us to send your application?

	US Mail
	Email
	FAX

* In chronological order, please list all hospitals at which you have held clinical privileges during the last two years (example: Hospital - Address - Dates).

* The following physician(s) with Mills-Peninsula Health Services Admit & Manage privileges has explicitly agreed to provide continuing coverage for my patients when I am not available:

If not applicable, please explain:

The following are required to be eligible to apply:

You will be asked to supply documentation once this application is received.

Current license to practice in the state of California
DEA registration, if applicable
Proof of professional liability coverage which indicates effective date, amount and classification of coverage ($1/3 million required)
Proof of successful completion of an accredited post-graduate training program or allied health training program
ECFMG certificate (if foreign medical graduate)
Evidence of board certification (if applicable) or letter from certifying board indicating your admission to sit for examination
Current curriculum vitae (CV)
Birth date and Social Security number, if not included in CV
Photograph (will be used on website and for identity verification).

If you do not have these documents, please provide information as to why not (i.e., completing residency training) and when you will have this documentation. Before your application may be considered, these documents must be submitted.