Allied Health Staff Forms
The following documents
are utilized for appointment and reappointment to the Allied Health
Staff of Hendrick Medical Center:
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.
* Criminal History Affidavit - This document is required of all initial applicants.
Consent and Release – This document releases
all members of the Hospital, Medical Staff, Board of Trustess 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
Evaluation – This document needs to be forwarded
to your personal physician for completion. This information is
a requirement of the Hendrick Medical Center Allied Health Professional
Staff appointment and reappointment processes.
Test Form – This document needs to be completed
by the appropriate healthcare professional at Hendrick Medical
Center Employee Wellness Office or by a physician on a yearly basis.
Scope of Practice/Clinical Privilege Request Forms – You must contact the Medical
Staff Office to obtain these documents.
Checklist – You
must contact the Medical Staff Office to obtain this document.
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 the Tammy
Estes, in the Medical Staff Office at 325.670.3465.