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If
you are eligible for privileges as a member of the hospital Medical Staff
or healthcare network of a TPQVO client facility but are not a physician, dentist,
or podiatrist, you will need to complete the appropriate application form
listed under
FORMS. If you are a physician, dentist or podiatrist, go
to Physician Application Forms.
Initial
Application Process
Some
TPQVO client organizations require pre-application screening and will
not accept an application without first contacting the medical staff or
professional relations office. Please contact the healthcare
organization's office first if you have any question about your
eligibility for membership/affiliation.
Reappointment
Applications
TPQVO
will send the appropriate application for reappointment or recredentialing to
medical staff and network members according to the regional
reappointment schedule. Therefore, these forms are not available
through this website.
Depending upon the healthcare organization to which you are applying,
forms are available for download on this page in Adobe Reader format. The forms may be
filled and printed and then sent or faxed to TPQVO for processing.
If you have any questions about
the appropriate form for your circumstances, please call the healthcare
organization (TPQVO client) to which you are applying or reapplying for
privileges.
File Maintenance and Query Fees
There
is a file maintenance fee charged for any first time application for
initial privileges. This fee is noted on the cover letter
describing all necessary documentation that you must send in with your
completed application. TPQVO
will not begin processing your file until this fee is paid. Also,
most healthcare organizations will not accept an
application as complete without the additional items listed on the cover
letter.
Additionally,
TPQVO will bill you for any primary source query fee (i.e., graduate
schools, national certification boards) charged to TPQVO for providing a
verification of your credential. You will not be billed for
information TPQVO can reuse from previous times your file was processed
for a TPQVO client facility.
Questions? Contact us at tpqvo@tpqvo
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The
forms below are available as Adobe® Acrobat® Reader™ PDF
files. If you need this free software, click on the Adobe® button
below and you will be directed to the download site.
FORMS
Chattanooga/North
Georgia Area:
Initial
Application
Hutcheson Medical Center
Pre-application
Memphis,
Knoxville, Nashville,
and all other areas:
Initial Application
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