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Request for Application

You must provide the following required information in order to request/access the credentialing application. Please fill in the required fields and then click on "Send message" at the bottom of the page.

*Name:
*Anticipated date starting practice:
*Current Address:	Street:
	City: State: Zip:
Email address:
*Phone number where you can be reached (in format (area code) xxx-xxxx):	Office: Home: Cell:
*Date of Birth:
Social Security Number:
Type of practitioner:	MD DO DMD/DDS PA NP PhD/PsyD NM DC OD DPM MA(masters in Psychology) Perfusionist RN CST Surgical/Dental/Medical Asst SW LPC RNFA CRNA Other (specify):
Sponsor Name: (Applies to Allied Health only)
Name of office/practice which you will be joining:
*Are you joining Novant Medical Group?	Yes No	If yes, will you be employed by NMG or be privately contracted by an outside agency? employed privately contracted
*Will you be a solo practitioner:	Yes No ** - If so, please name the physician who will be providing back-up coverage for your patients. Enter 'unknown' if backup physician has not yet been identified.
*Will you be working as a Locum Tenens?	Yes No - If yes, what is your anticipated length of assignment? - If yes, please indicate which group/practitioner you will be covering
*To which Novant facility will you consider your primary practice location? (please choose one)	Brunswick Forsyth Franklin Medical Park Presbyterian Prince William Rowan Thomasville Upstate Carolina Other (specify):
Additional Facilities: (choose all that apply)	Brunswick Forsyth Franklin Medical Park Presbyterian Prince William Rowan Thomasville Upstate Carolina Presbyterian Midtown Surgery Center Ballantyne Surgery Center Monroe Surgery Center SouthPark Surgery Center Huntersville Surgery Center Other (specify): ** - If you will be applying for privileges at Brunswick, Forsyth, Franklin, Medical Park, Rowan, Prince William, Thomasville or Upstate Carolina, you will be contacted for additional paperwork that will be required.
*Specialty: (list all)
*Board Certification status:	Certified Eligible Not Certified
Do you want us to mail the application packet?	Yes No
Address to mail packet if different from address listed above:	Street address:
	City: State: Zip:

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