Medical Staff Advanced Practice Professionals Application for Privileges

Name

First NameLast NameSuffix

Please select which location(s) you will need privileges for:

Indicate your primary facility

Department/Specialty

Title

PLEASE NOTE:

If you will be employed by TGH/TGMG, please select the TGH/TGMG group name that corresponds with your specialty.

If you will be employed by USF, please select the USF group name that corresponds with your specialty.

Group Name

Other Group Name

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.

Preferred E-mail Address (please note, the e-mail address the application is sent to will be used for all TGH correspondence)

Preferred Contact Number

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

Headshot

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

Are you applying as a Locums Tenens?

Were you previously credentialed at TGH?

What year did you come off staff?

Are you:

What Board are you Certified in?

If Other - please list your board

Name and Title

Group Name and Address

Group Tax ID

Home Address

Contact Preferences

Office Administrator Contact Information

Personal Information

Required Documents

Employment