Medical Staff

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Application and Reapplication of Medical Staff privileges at Anderson Hospital.

Application:

Physicians:

Step 1: Download the Illinois Department of Public Health Online Application.

Step 2: Download this PDF File, Complete and Return to Medical Staff Office.

Allied Health Staff:

Step 1: Download the Illinois Department of Public Health Online Application.

Step 2: Download this PDF File, Complete and Return to Medical Staff Office

Reapplication:

Physicians:

Step 1: Download the Illinois Department of Public Health Online Application.

Step 2: Download this PDF File, Complete and Return to Medical Staff Office

Allied Health Staff:

Step 1: Download the Illinois Department of Public Health Online Application.

Step 2: Download this PDF File, Complete and Return to Medical Staff Office

Forms:

  1. Initial Application Letter
  2. Application Checklist
  3. Application Fee Sheet
  4. Supplemental Forms
  5. Staff Status Descriptions
  6. Attestation
  7. Consent to Release
  8. Health Statement
  9. Background Check 
  10. Conflict of Interest Agreement
  11. Autofaxing Enrollment 
  12. Certificate of Insurance
  13. Provider Signature Card
  14. Provider Contact Information
  15. Professional Reference Questionnaire