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Credentialing Applications

Here you'll find everything you need for the credentialing process at Providence Regional. Please note that there are different forms for LIP's vs. Allied Health providers. Contact Karen Anderson at (425) 261-3087 if you have any questions. Return your completed forms via fax at (425) 261-3095, email at prmcemedicalstaffservices@providence.org or mail:

PRMCE Medical Staff Office
1321 Colby Ave
Everett, WA 98201

Forms for LIP's (MD, DO, DPM, DDS, PhD, ARNP, CNM, CRNA)

Forms for Allied Health Providers (RNFA, PA-C, DA, MSW, MA)

PRMCE uses the Epic Electronic Health Record.   Proficiency in its use must be demonstrated prior to having access to Epic.  Training is available.  See the Epic section in the left-hand column. 


For LIP's (MD, DO, DPM, DDS, PhD, ARNP, CNM, CRNA)

Instructions:

Initial Application Instructions (PDF)
Medical Staff Membership: General Qualifications (PDF)
Bylaws (PDF)
Privilege Explanation Letter (PDF) email Karen Anderson with your Specialty and the appropriate privileging forms will be sent back to you.

Forms to be completed and returned:

Washington Practitioner Application (PDF)
National Background Check Release (online form to complete: User ID 7935)
Signature Pages (PDF)
Disclosure Statement (PDF)
Medicare and Tricare Notification (PDF)
Infection Control Post-test (PDF)  Infection Control Overview (PDF)
Annual TB Screening Form (.doc) (if applicable)
PRMCE Flu Attestation and Declination Form (PDF)
Code of Conduct Acknowledgement and Acceptable Use Agreement (PDF)
Fluoroscopy Privileges (if applicable) - Fluoroscopy Criteria (PDF), Fluoroscopy Exam (PDF), Fluoroscopy Manual (PDF)
Moderate Sedation Privileges (if applicable) – Sedation Policy (PDF) Sedation Manual (PDF) Sedation Exam (PDF)
Parking Registration (DOC) - Please return with your packet or bring with you to the photo shoot that you will schedule later in your process.
Cafeteria Credit Card Recurring Payment Form - specifically for those providers that wish to use their badge to charge food in the hospital cafeteria

Required reading - Governance Documents and Policies Applying to the Medical Staff:

Governance Documents
Ethical and Religious Directives (PDF)
Immunization Policy
Life Support Training Policy (DOC)
Mission, Vision, and Core Values (PDF)
Providence System Code of Conduct (PDF)
Compliance Education for Providence Medical Staff
Compliance Coordination with the Medical Staff (PDF)

Medical Staff Integrity Brochure (PDF)


For Allied Health Providers (RNFA, PAC, DA, MSW, MA)

Instructions:

Initial Application Instructions (PDF)
Bylaws (PDF)
Privilege Explanation Letter (PDF) email Karen Anderson with your Specialty and the appropriate privileging forms will be sent back to you.

Forms to be completed and returned:

Washington Practitioner Application (PDF)
National Background Check Release (online form to complete: User ID 7935)
Signature Pages (PDF)
Disclosure Statement (PDF)
Medicare and Tricare Notification (PDF)
Infection Control Post-test (PDF)  Infection Control Overview (PDF)
Annual TB Screening Form (.doc) (if applicable)
PRMCE Flu Attestation and Declination Form (PDF)
Code of Conduct Acknowledgement and Acceptable Use Agreement (PDF)
Fluoroscopy Privileges (if applicable) - Fluoroscopy Criteria (PDF), Fluoroscopy Exam (PDF), Fluoroscopy Manual (PDF)
Moderate Sedation Privileges (if applicable) – Sedation Policy (PDF) Sedation Manual (PDF) Sedation Exam (PDF)
Parking Registration (DOC) - Please return with your packet or bring with you to the photo shoot that you will schedule later in your process.
Cafeteria Credit Card Recurring Payment Form - specifically for those providers that wish to use their badge to charge food in the hospital cafeteria

Required reading - Governance Documents and Policies Applying to the Medical Staff:

Governance Documents
Ethical and Religious Directives (PDF)
Immunization Policy
Life Support Training Policy (.doc)
Mission, Vision, and Core Values (PDF)
Providence System Code of Conduct (PDF)
Compliance Education for Providence Medical Staff
Compliance Coordination with the Medical Staff (PDF)
Medical Staff Integrity Brochure (PDF)