Credentialing Applications
Here you'll find everything you need for the credentialing process at Providence Regional. Please note that there are different forms for physicians vs. allied health providers. Contact Karen Anderson at 425-261-3087 if you have any questions.
Return your completed forms to:
PRMCE Medical Staff Office
P.O. Box 1147
Everett WA 98206
Forms for Physicians (MD, DO, DPM, DDS, PhD)
Forms for Allied Health Providers (ARNP, CNM, CRNA, RNFA, PA-C, DA, MSW, MA)
For Physicians (MD, DO, DPM, DDS, PhD)
Instructions:
Initial Application Instructions (PDF)
Medical Staff Membership: General Qualifications (PDF)
Bylaws (PDF)
Privilege Explanation Letter (PDF) email Karen Anderson with your Specialty and the appropriate privileging forms will be sent back to you.
Forms to be completed and returned:
Washington Practitioner Application (PDF)
National Background Check Release (PDF)
Signature Pages (PDF)
Applicant's Intended Practice Plan (PDF)
Disclosure Statement (PDF)
Medicare and Tricare Notification (PDF)
Tuberculosis Symptoms Checklist (.doc) (if applicable)
PRMCE Flu Attestation and Declination Form (PDF)
Code of Conduct Acknowledgement and Acceptable Use Agreement (PDF)
Fluoroscopy Privileges (if applicable) - Fluoroscopy Criteria (PDF), Fluoroscopy Exam (PDF), Fluoroscopy Manual (PDF)
Moderate Sedation Privileges (if applicable) – Sedation Policy (PDF) Sedation Manual (PDF) Sedation Exam (PDF)
Required reading - Governance Documents and Policies Applying to the Medical Staff:
Governance Documents
Ethical and Religious Directives (PDF)
Immunization Policy (PDF)
Life Support Training Policy (.doc)
Mission, Vision, and Core Values (PDF)
PPD Testing Policy (PDF)
Providence System Code of Conduct (PDF)
Medical Staff Integrity Brochure (PDF)
For Allied Health Providers (ARNP, CNM, CRNA, RNFA, PA-C, DA, MSW, MA)
Instructions:
Initial Application Instructions (PDF)
Bylaws (PDF)
Privilege Explanation Letter (PDF) email Karen Anderson with your Specialty and the appropriate privileging forms will be sent back to you.
Forms to be completed and returned:
Washington Practitioner Application (PDF)
National Background Check Release
Signature Pages (PDF)
Disclosure Statement (PDF)
Medicare and Tricare Notification (PDF)
Tuberculosis Symptoms Checklist (.doc) (if applicable)
PRMCE Flu Attestation and Declination Form (PDF)
Code of Conduct Acknowledgement and Acceptable Use Agreement (PDF)
Fluoroscopy Privileges (if applicable) - Fluoroscopy Criteria (PDF), Fluoroscopy Exam (PDF), Fluoroscopy Manual (PDF)
Moderate Sedation Privileges (if applicable) – Sedation Policy (PDF) Sedation Manual (PDF) Sedation Exam (PDF)
Required reading - Governance Documents and Policies Applying to the Medical Staff:
Governance Documents
Ethical and Religious Directives (PDF)
Immunization Policy (PDF)
Life Support Training Policy (.doc)
Mission, Vision, and Core Values (PDF)
PPD Testing Policy (PDF)
Providence System Code of Conduct (PDF)
Medical Staff Integrity Brochure (PDF)