Medical Staff Advanced Practice Professionals Application for Privileges

Name*

First NameLast NameSuffix

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

Department/Specialty*

Title*

Group Name*

Other

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Office Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Office Fax*

Please enter a valid phone number.Format: (000) 000-0000.

Group Tax ID#*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Personal EmailWork Email

CellHomeOffice

Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

NPI Registry

DOB*

SSN*

Personal Email*

example@example.com

Work Email

example@example.com

Cell Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Advanced Professional Education*

Graduation Date*

Date

NPI*

CV*

Anticipated Start Date*

Name of Supervising Physician at TGH**

*Must hold privileges at TGH

Are you employed by TGH or TGMG?*

Are you privileged at BHP or Morsani ASC *

ID Number*

Are you applying as a Locums Tenens? *

Were you previously credentialed at TGH?

What year did you come off staff?

Board CertifiedNot Board Certified

If Other - please list your board*

Name and Title

Office Address

Group Tax ID

Home Address

Contact Preferences

Office Administrator Contact Information

Personal Information

Curriculum Vitae (CV)

Heading

Employment