Request For Credentialing

Last Name:* First Name:* MI:

Specialty:* Subspecialty:

Social Security Number:*

Are you a: (check all that apply)*

Physician (MD/DO) Dentist (DMD/DDS) House Physician

Nurse Practitioner Physician Assistant Psychiatrist

Psychologist Other Please specify other:

Will you be a hospital employee?* Yes No

Will you be joining as part of the Hospitalist Program?* Yes No

Requesting Privileges at: (check all that apply)*

Virtua Hospitals (includes Berlin, Marlton, Mt. Holly, Voorhees)

Advanced Surgical Summit Surgical

Rehab Center at Mt. Holly Rehab Center at Berlin

Ambulatory Surgery Center at Virtua Washington Township

Mail application to this address

Practice Name:*

Address 1:*

Address 2:

City:* State:* Zip:*

Phone:* Fax:

Mail application to this address

Address:*

City:* State:* Zip:*

Phone:* Fax:

E-mail:*

Confirm E-mail:*

Are you currently Board Certified in your practicing specialty?* Yes No

Cert Date:

Name of Certifying Board:*

Are you board eligible?* Yes No

If board eligible, when did you complete residency/fellowship program?* Year:

Type of last residency/fellowship program completed?*

Board certification is required within 5 years of training completion.

Do you plan to meet this requirement?* Yes No Requirement Met

Do you have a current:*

New Jersey Medical license Yes No If not, when: (month/year)

New Jersey CDS Yes No If not, when: (month/year)

DEA with NJ address Yes No If not, when: (month/year)

Professional Liability Insurance Yes No If not, when: (month/year)