Medical Staff

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Application and Reapplication of Medical Staff privileges at Anderson Hospital.

Application:

Physicians:

Step 1: State of Illinois Forms: Illinois Health Care Professional Credentialing and Business Data Gathering Form

Step 2: Anderson Hospital’s Forms: Application for Appointment

Step 3: Complete and return both forms to the Medical Staff Office.

Allied Health Professionals:

Step 1: State of Illinois Forms:Illinois Health Care Professional Credentialing and Business Data Gathering Form

Step 2: Anderson Hospital’s Forms: Application for Appointment

Step 3: Complete and return both forms to the Medical Staff Office.

Reapplication:

Physicians:

Step 1: State of Illinois Forms: Illinois Health Care Professional Recredentialing and Business Data Gathering Form

Step 2: Anderson Hospital’s Forms: Application for Reappointment

Step 3: Complete and return both forms to the Medical Staff Office.

Allied Health Professionals:

Step 1: State of Illinois Forms: Illinois Health Care Professional Recredentialing and Business Data Gathering Form

Step 2: Anderson Hospital’s Forms: Application for Reappointment

Step 3: Complete and return both forms to the 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