Request for Physician Application

This request will be evaluated to determine if you meet facility eligibility for membership and privileges. If you meet criteria, you will receive an application.
Name and Title
Name*

First NameLast NameSuffix
Title*
Department/Specialty*
Please select which location(s) you will need privileges for:*

TGH Main (Davis Island)TGH Behavioral Health Hospital (invitation only)TGH Rehabilitation Hospital (invitation only)TGH Surgery Center BrandonTGH Surgery Center at MorsaniUniversity of Tampa - Student Health Clinic (student health clinic providers only)
Indicate your primary facility:*

TGH Main (Davis Island)TGH Behavioral Health Hospital (invitation only)TGH Rehabilitation Hospital (invitation only)TGH Surgery Center BrandonTGH Surgery Center at MorsaniUniversity of Tampa - Student Health Clinic (student health clinic providers only)
Are you Telemed?*

YesNo
Are you applying to an ASC (Brandon or Morsani Surgery Center)?*

YesNo
Which ASC are you applying to?*

TGH Surgery Center BrandonTGH Surgery Center at Morsani
What cases do you plan to bring to TGH Surgery Center Brandon?*
What cases do you plan to bring to TGH Surgery Center at Morsani?*
Office Address

*If you work for TGH/TGMG, please select the TGH/TGMG group name that corresponds with your specialty, do NOT select Other. *If you work for USF, please select the USF group name that corresponds with your specialty, do NOT select Other.
Group Name (Addiction Medicine)*
Group Name (Adult Reconstructive Orthopaedic Surgery)*
Group Name (Advanced Heart Failure & Transplant Cardiology)*
Group Name (Allergy & Immunology)*
Group Name (Anatomic Pathology & Clinical Pathology)*
Group Name (Anesthesiology)*
Group Name (Bariatric Medicine)*
Group Name (Bariatric Surgery)*
Group Name (Blood Banking & Transfusion Medicine)*
Group Name (Bone Marrow Transplantation)*
Group Name (Breast Surgery)*
Group Name (Cardio-thoracic Anesthesia)*
Group Name (Cardiovascular Disease)*
Group Name (Child & Adolescent Psychiatry)*
Group Name (Clinical Cardiac Electrophysiology)*
Group Name (Clinical Neurophysiology)*
Group Name (Colon & Rectal Surgery)*
Group Name (Cornea & External Diseases)*
Group Name (Critical Care Medicine)*
Group Name (Dentistry - Oral & Maxillofacial Surgery)*
Group Name (Dermatology)*
Group Name (Diagnostic Radiology)*
Group Name (Emergency Medicine)*
Group Name (Endocrinology, Diabetes & Metabolism)*
Group Name (Family Medicine)*
Group Name (Female Pelvic Medicine & Reconstructive Surgery)*
Group Name (Foot & Ankle Surgery)*
Group Name (Gastroenterology)*
Group Name (General Surgery)*
Group Name (Geriatric Medicine)*
Group Name (Gynecologic Oncology)*
Group Name (Gynecology)*
Group Name (Hand Surgery)*
Group Name (Hematology)*
Group Name (Hematology & Oncology)*
Group Name (Hepatology)*
Group Name (Hip & Joint Surgery)*
Group Name (Hospice & Palliative Care)*
Group Name (Hospital Medicine)*
Group Name (Infectious Disease)*
Group Name (Internal Medicine)*
Group Name (Internal Medicine & Pediatrics)*
Group Name (Interventional Cardiology)*
Group Name (Maternal & Fetal Medicine)*
Group Name (Medical Oncology)*
Group Name (Medical Toxicology)*
Group Name (Neonatal-Perinatal Medicine)*
Group Name (Nephrology)*
Group Name (Nephrology Transplantation (Non-Surgical))*
Group Name (Neurocritical Care)*
Group Name (Neurological Skull Base Surgery)*
Group Name (Neurological Spine Surgery)*
Group Name (Neurological Surgery)*
Group Name (Neurology)*
Group Name (Neuro-Ophthalmology)*
Group Name (Neuroradiology)*
Group Name (Nuclear Cardiology)*
Group Name (Nuclear Radiology)*
Group Name (Obstetrics & Gynecology)*
Group Name (Ophthalmic Plastic & Reconstructive Surgery)*
Group Name (Ophthalmology)*
Group Name (Orthopaedic Musculoskeletal Oncology)*
Group Name (Orthopaedic Surgery)*
Group Name (Orthopaedic Surgery of the Spine)*
Group Name (Orthopaedic Trauma)*
Group Name (Orthopaedic Trauma Surgery)*
Group Name (Otolaryngology)*
Group Name (Pain Medicine)*
Group Name (Pediatric Allergy/Immunology)*
Group Name (Pediatric Anesthesiology)*
Group Name (Pediatric Bariatric Medicine)*
Group Name (Pediatric Cardiology)*
Group Name (Pediatric Critical Care Medicine)*
Group Name (Pediatric Dentistry)*
Group Name (Pediatric Emergency Medicine)*
Group Name (Pediatric Endocrinology)*
Group Name (Pediatric Gastroenterology)*
Group Name (Pediatric Genetics)*
Group Name (Pediatric Hematology-Oncology)*
Group Name (Pediatric Hospital Medicine)*
Group Name (Pediatric Infectious Diseases)*
Group Name (Pediatric Nephrology)*
Group Name (Pediatric Neurology)*
Group Name (Pediatric Neurosurgery)*
Group Name (Pediatric Ophthalmology & Strabismus)*
Group Name (Pediatric Orthopaedic Surgery)*
Group Name (Pediatric Otolaryngology)*
Group Name (Pediatric Pathology)*
Group Name (Pediatric Pulmonary)*
Group Name (Pediatric Rehabilitation Medicine)*
Group Name (Pediatric Sleep Medicine)*
Group Name (Pediatric Surgery)*
Group Name (Pediatric Urology)*
Group Name (Pediatrics)*
Group Name (Physical Medicine & Rehabilitation)*
Group Name (Plastic & Reconstructive Surgery)*
Group Name (Plastic Surgery)*
Group Name (Plastic Surgery within the Head & Neck)*
Group Name (Podiatry)*
Group Name (Preventive Medicine/Occupational Environmental Medicine)*
Group Name (Procurement)*
Group Name (Psychiatry)*
Group Name (Psychology)*
Group Name (Psychology - Behavioral Pain Management)*
Group Name (Psychology - Behavioral Sleep Medicine)*
Group Name (Psychology - Clinical)*
Group Name (Psychology - Clinical Child & Adolescent)*
Group Name (Psychology - Health)*
Group Name (Psychology - Neurophysiology)*
Group Name (Psychology - Pediatric Neuropsychology)*
Group Name (Psychology - Rehabilitation)*
Group Name (Pulmonary Disease)*
Group Name (Pulmonary Transplantation (Non-Surgical))*
Group Name (Radiation Oncology)*
Group Name (Reproductive Endocrinology)*
Group Name (Retina)*
Group Name (Rheumatology)*
Group Name (Shoulder & Elbow Surgery)*
Group Name (Sleep Medicine)*
Group Name (Spinal Cord Injury Medicine)*
Group Name (Sports Medicine)*
Group Name (Surgical Critical Care)*
Group Name (Surgical Oncology)*
Group Name (Thoracic Surgery (Cardiothoracic Vascular Surgery))*
Group Name (Transplant Hepatology)*
Group Name (Transplant Surgery (Abdominal))*
Group Name (Transplant Surgery (Cardiothoracic))*
Group Name (Trauma Surgery)*
Group Name (Urology)*
Group Name (Vascular & Interventional Radiology)*
Group Name (Vascular Surgery)*
Other
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Phone*
Please enter a valid phone number.
Office Fax*
Please enter a valid phone number.
Group Tax ID
Group Tax ID#*
Home Address
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Contact Preferences
Email Application to*

Personal EmailWork Email
Preferred Contact Number*

CellHomeOffice
Office Administrator Contact Information
Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Personal Information
NPI Registry
DOB*

MonthDayYear
Date
SSN*
Personal Email*
example@example.com
Work Email
example@example.com
Cell Phone*
Please enter a valid phone number.
Degree*
Medical School*
Graduation Date*

MonthDayYear
Date
NPI*
Board Certification
Are You*

Board CertifiedBoard EligibleNot Board Certified and Not Board Eligible
I Am Currently Board Certified By

American Board of Medical Specialties (ABMS) Member BoardAmerican Osteopathic Association (AOA)American Board of Podiatric Surgery (ABPS)American Board of Podiatric Medicine (ABPM)American Dental Association (ADA)American Board of Oral/Maxillofacial Surgeons (ABOMS)
Curriculum Vitae (CV)
CV*

Cancelof
Employment
Anticipated Start Date*

MonthDayYear
Were you previously credentialed at TGH?*
What year did you come off staff?
Are you employed by TGH or TGMG?*
Are you applying as a Locum Tenens?*
Are you privileged at BHP or Morsani ASC?*
ID Number*
Are you in a current residency or fellowship program with USF? *
Will you be moonlighting with USF/TGH during your training program? *
Have you submitted an application for approval to moonlight to USF GME? *
Please note USF GMEC approval is required to obtain privileges to moonlight
Are you Active Duty Military?*
Please indicate branch of service*

AirforceArmyMarinesNavyCoast Guard
Supervisor's Name*
Supervisor's Phone Number*
Please enter a valid phone number.
Covering Provider

Required if requesting privileges at TGH Main
Covering provider with active privileges at Tampa General Hospital
Should be Empty:

This request will be evaluated to determine if you meet facility eligibility for membership and privileges. If you meet criteria, you will receive an application.

Name and Title

Office Address

Group Tax ID

Home Address

Contact Preferences

Office Administrator Contact Information

Personal Information

Board Certification

Curriculum Vitae (CV)

Employment

Covering Provider