IU Health Application for Privileges
Thank you for your interest in applying for medical staff membership and clinical privileges in one of our IU Health facilities. Prior to submitting a request for membership, please review all Threshold Eligibility Criteria to apply for and maintain privileges as listed in our Credentials Manual.
Once you have reviewed the threshold eligibility criteria, you will begin the application process by completing the Request for Membership Form. Please print and fax the completed form to (317) 968-1060 or email to email@example.com.
Once the request for Membership is submitted, we will send you a link and password to your personal Practitioner Home Page, a unique online portal developed to centralize all applicant requirements. The PHP includes an application checklist making it easy for the providers to quickly and efficiently complete the application and all supplemental documentation required for Primary Source Verification.
Application requirement include but may not be limited to:
- Completion of the IU Health Online Application
- eSigned Authorization, Consent, and Release
- Request for Privileges
- Professional Photo (Color/B&W, 21/2 x 31/2 inches)
- Copy of State ID, Driver's License, Visa, or Passport
- Curriculum Vitae
- Current Malpractice Insurance
- Copies of Resuscitation Certifications (ACLS, BLS, PALS)
- Military Forms (if applicable)
- Information Services: Responsibility Statement and OLAR
- Proof of completion for Continuing Education (CME)
- Health Evaluation and TB forms
- Current Collaborative Agreements/ Job Descriptions (AHP)
- Payment of Application Fee