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 II 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.

Addendum to the Texas Standardized Credentialing Application – This document contains information required by Hendrick Medical Center that is not included on the Texas Standardized Credentialing Application.

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.

*Photograph – A photograph is required for all new applicants, therefore, we must receive a current, dinstinguishable photo before we can proceed with the processing of your application.

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

* Acknowledgement Form - Completion of Medical Records - This document is required related to the completion of medical records.

* 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.

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/Medicaid Attestation – This document is required upon initial application as mandated by federal regulations.

* HIN and ESA Contract - Hendrick Medical Center requires all users of the HIN product to have a current contract between the physician and Hendrick Medical Center and Affiliates (HMC) to allow usage of the HIN product and associated computer software services offered by HMC

* 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.