Medical Staff Forms
The following documents are utilized for initial appointment and/or reappointment to the Medical Staff of Hendrick Medical Center. Initial applicants must return all of the documents. Reappointment applicants only need to return the documents indicated by the asterisk.
Application Cover Letter - Please read this letter and utilize the included check list to ensure 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 prior to inputting pertinent information.
Initial Application Addendum - This addendum must be utilized by 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.
* 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 initial applicants for Medical Staff membership and privileges at Hendrick Medical Center and ContinueCARE Hospital at Hendrick Medical Center. All initial applicants are required to provide this executed affidavit.
DPS Criminal History Form - All initial applicants are required to provide this executed affidavit. 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 initial applicants and all Affiliate and Referring Staff reappointment applicants. It is utilized to determine current competence.
Medicare/Medicaid Attestation – This document is required upon initial application as mandated by federal regulations.
Medical Records Acknowledgement - This document outlines requirements for completion of medical records and is required upon initial application.
HIN Contract - This license agreement for access to Hendrick Information Network is required upon initial application.
* These documents are required for reappointment.
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.