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To request a change of practice/sponsor and/or add an additional sponsor, please download the AHP Application for Change of Practice/Sponsor Form.

Please complete the form and submit it to the Medical Staff Office.  As soon as we receive your completed application and required information, we will update our database and your requested changes will be reported at the next Credentials Committee meeting.  You will be permitted to work in the hospital setting under the new sponsor provided we receive/confirm the following:

• Completed Change of Practice Information signed by both you and your new sponsor. 
• Signed Scope of Practice Attestation (see below for links to Allied Health scopes of practice);
• Updated insurance showing you are covered while working for your new practice;
• A copy of your updated DEA certificate (if applicable) with current address;
• Verification from the appropriate licensing board that you are approved to work for your new sponsor.

When you receive a copy of your Statement of Approval Letter or Intent to Practice Letter from your licensing board which shows you are approved to work with your new sponsor, please fax that document to our office for inclusion in your file. 

Fax forms and required documentation to (704) 316-1308
or mail to Dwaina Humphries at the following address:

Medical Staff Services     •    200 Hawthorne Lane     •      Post Office Box 33549     •    Charlotte, NC 28233-3549