Medical Staff Forms

The following documents are utilized for appointment and/or reappointment to the Medical Staff of Hendrick Medical Center:

* Application Cover Letter - Please read this letter and utilize the included check list to ensure that you are returning all of the required application documents.

* Application Policy – Article I of the Credentials Policy and Procedure Manual of the Medical Staff Bylaws stipulates the basic criteria for providing an application to a licensed medical and osteopathic physician, podiatrist and dentist.

* Tips for Expediting Your Application – This document contains tips on what you can do to expedite the processing of your application.

Texas Standardized Credentialing Application – This document is located on the Texas Department of Insurance website. To ensure that you do not lose data you must save the document to your computer first and then input pertinent information.

*Initial Application Addendum - This addendum is required of all initial applicants. It contains information not included on the Texas Standardized Credentialing Application that Hendrick Medical Center is required to obtain. Some of the questions may seem redundant but they are different.

Reappointment Addendum - This addendum must be utilized by practitioners who are already on staff and are requesting reappointment. It contains information not included on the Texas Standardized Credentialing Application that Hendrick Medical Center is required to obtain. Some of the questions may seem redundant but they are different.

Applicant’s Consent and Release – This document releases all members of the Hospital, Medical Staff, Board of Trustees of the Hospital, and its committees from any liability in carrying out their respective duties and responsibilities including, but not limited to, the evaluation of the member’s qualifications for appointment, reappointment, clinical privileges, and periodic appraisal thereof. Upon signing this release, each applicant attests that they have had an opportunity to read a copy of the Medical Staff Bylaws, manuals, policies and procedures and agrees to abide by such documents.

Clinical Privilege Request Forms – You must contact the Medical Staff Office to obtain these documents.

* Criminal History Affidavit - A criminal records check will be conducted on all applicants for Medical Staff membership and privileges at Hendrick Medical Center and Hendrick Center for Extended Care. Applicants are required to provide this executed affidavit.

* DPS Criminal History Form - The Texas Department of Public Safety requires HMC maintain this form for audit purposes.

Physician Profile/Case List – The information outlined in this document must be provided by all new applicants and all Affiliate Staff reappointment applicants and is utilized to determine current competence.

* Medicare/MedicaidAttestation – This document is required upon initial application as mandated by federal regulations.

* Medical Records Acknowledgement - outlines requirements for completion of medical records. – This document is required upon initial application as mandated by federal regulations.

* HIN Contract - License agreement for access to Hendrick Information Network

* These documents only need to be utilized upon initial application.

Please print and complete each of these documents and return them to Hendrick Medical Center, Medical Staff Office, 1900 Pine Street, Abilene, Texas 79601. If you have any questions, please contact Tracey Gilliam, CPMSM, in the Medical Staff Office at 325.670.3408.