Request for Credentialing - Practitioner Onboarding

Practitioner Information

Please complete all areas on form. Incomplete forms will not be accepted. Indicate N/A if an area is not applicable. Processing of request will not begin until completed form is submitted.

Today's date

Date

Practitioner Name (full name as listed on Medical License or Social Security Card)

First Name

Last Name

Practitioner Credentials (MD, DO, CRNA, APRN, PA-C, etc.)

Is practitioner a Resident Fellow or Moonlighting?

Yes

Is practitioner a Chief Resident?

Yes

Is practitioner an Advanced Practice Professional (APP)?

Yes

Primary Supervising Physician Name (if practitioner is APRN, CRNA, AA or PA-C)

First Name

Last Name

Is the practitioner Board Certified or Eligible? Physicians must be Board certified or meet eligibility requirements outlined per Medical Staff Bylaws. Allied Health Professionals (AHP's) must be Board Certified.

Yes

Does the practitioner require a board certification waiver? If yes, submit the Request for a Temporary Board Certification Waiver form

Yes

Download Temporary Board Certification Waiver (.docx)

Temporary Board Certification Waiver Upload

Select "Chose File" to upload

Primary Specialty Practitioner Will Practice

Additional Specialty Practitioner Will Practice (if Applicable)

Practitioner Cell Phone Number

Practitioner Email

Practitioner's CV (must be PDF)

Department Information

The following areas are available for the contact to select if their provider is not part of the Florida Clinical Practice Association under a UF College of Medicine department: Central Florida Health, Eagle Telemedicine, First Coast Heart & Vascular, St. Johns/Flagler Hospital, TeamHealth/Leesburg Regional Medical Center, Archer Family Health Care, Clinical and Health Psychology, Hospital Dental Service, and Shands (Registered Dietitian, Audiologist). Please contact Leilani Johnson at ljoh0003@shands.ufl.edu/Leilani.Johnson@ufhealth.org if you believe your area is missing.

Department Contact

Department Contact's Email

Department Phone

Practitioner's Practice

Is practitioner being credentialed as an Attending while enrolled in the Fellowship Training Program?

Yes

Is the practitioner a short-term/Locums Tenens applicant?

Yes

Locum Agency Name

Locum Agency Phone

Locum Agency Contact Name

First Name

Last Name

Locum Agency Contact Email

Please indicate the type of services the practitioner will practice:

Please indicate which hospital(s) the practitioner will be required to have hospital privileges:

UF Health Shands Hospitals (includes all locations)

Select Specialty Hospital

UF Rehab Hospital

N/A - Clinic only Practitioner

Will UF Health be billing for practitioner's professional services?

Yes

Comments (if credentialed with other UF Health Med Staff Office, please notate i.e. CFH, STJ, UF Jax)

Reference the UF Faculty Practice Sites Document below to locate 6-digit Site Number and Name:

UF Health Office Sites and Numbers

Primary Office Site Number and Name

Secondary Office Site Number and Name

Office #3 Site Number and Name