Required Documents

Please return all applications to:

Emory Healthcare
Medical Staff Services & System Credentialing
101 West Ponce de Leon Avenue, Suite 300
Decatur, Georgia 30030

Office: (404) 778-5034
Fax: (404) 778-4819

PLEASE NOTE:

• Keep a copy of your original application, either saved on your computer or a hard copy for future use.
• Maintain the form(s) by updating with new information as needed.
• Every time you are credentialed, the Hospital, Health Plan and/or other Healthcare Entity(ies) will require your signature and date on a new "Authorization and Signature" page. This form allows the plan or hospital to verify the information you've included on your application by confirming it from primary sources. It also contains an attestation stating that the information on your application is current and true to the best of your knowledge.
• Please review each copy of the application form prior to submitting to ensure that all sections are complete (incomplete forms will not be accepted!). Remember, in order for your application to be considered complete, you must submit Part One & Part Two simultaneously.
• All questions should be answered 'yes' or 'no' even if they do not apply.  Any unanswered question will only delay your application process.
• If you are going to provide services at Emory Medical Care Foundation (EMCF), you must apply for privileges at Grady Hospital. Grady Hospital handles their own credentialing of providers and this does not fall under the Emory Healthcare umbrella.
• Applicants should apply for their Georgia License, DEA and National Provider Identifier (NPI) numbers prior to completing and returning their application. The process for obtaining a Georgia License and/or DEA numbers can be lengthy. It will lessen the time your application spends in credentialing if you have obtained these numbers in advance.

Physicians Initial Documents Required 1 Georgia Uniform Credentialing Application (Part 1) complete & review for accuracy. Signed and dated. 2 Emory Healthcare Credentialing Application (Part 2) complete & review for accuracy. Signed and dated. 3 All disclosure questions have been answered with explanations provided for a "Yes" response. 4 Release/Attestation/Signature page has been signed (original signature) and dated. 5 New Privilege form has been completed (Please select the appropriate privilege form) 6 Copy of current Georgia Medical License (Wallet Size) (If you have not yet applied for your Georgia Medical License, please apply ASAP. Georgia Medical License Application Time Frame: Absent any complicating factors, the average application process takes approximately four (4) to six (6) weeks to complete. Once your application is completed you will be notified in writing by the State of the initial determination and the next scheduled Medical Board meeting date at which your application will be reviewed. 7 Copy of current DEA certificate enclosed (DEA Application Time Frame: New Applications (DEA Form 224) are processed within 4 to 6 weeks.) 8 Current CV (month/year format) with the last five (5) years of work history (include explanations for any six (6) month gap in experience or training). 9 Three (3) professional references. 10 Schedule B for explanation of malpractice claims history completed, if applicable. 11 Malpractice insurance certificate/Face sheet (Non-Emory Faculty only). 12 NPI number (if you do not have one you can apply online at https://nppes.cms/hhs.gov/NPPES/ It takes approximately 20 minutes to apply online and you normally have your NPI number within in a matter of hours at best to a few days at worst. 13 Current copy of a federal or state license document with signature and photograph (state driver's license or passport). 14 Continuing Medical Education (CME) Please attach documentation completed within the last two (2) years. 15 Expedited Credentialing Policy Signature Page, signed and dated. 16 PPD (Tuberculosis Status) Please attach results of PPD testing within the last twelve (12) months. 17 EJCH only: Confidentially Statement. 18 EJCH only: Reflex Testing 19 Infection Control Training. Please complete online at: https://www.emoryhealthcare.org/app/providerassessment/module/

Allied Health Initial Documents Required 1 Georgia Uniform Credentialing Application (Part 1) complete & review for accuracy. Signed by applicant and Primary Sponsor. 2 Emory Healthcare Credentialing Application (Part 2) complete, sign & review for accuracy. 3 All disclosure questions have been answered with explanations provided for any "Yes" responses. 4 Release/Attestation/Signature page has been signed (original signature) and dated. 5 New Privilege form has been completed (Please select the appropriate privilege form) signed by Primary Sponsor. 6 Copy of current Georgia Medical License (Wallet size) If you have not yet applied for your Georgia Medical License please apply ASAP. Georgia Medical License Application Time Frame: Absent any complicating factors, the average application process takes approximately four (4) to six (6) weeks to complete. Once your application is completed you will be notified in writing of the initial determination and the next scheduled Medical Board meeting date at which your application will be reviewed. 7 Copy of current DEA certificate enclosed DEA Application Time Frame: New Applications (DEA Form 224) are processed within 4 to 6 weeks. 8 Current CV (month/year format) with the last five (5) years of work history (include explanations for any 6 month gap in experience or training). 9 Three (3) professional references. 10 Schedule B for explanation of malpractice claims history completed, if applicable. 11 Malpractice insurance certificate/Face Sheet (Non-Emory faculty only). 12 NPI number (if you do not have one you can apply online at https://nppes.cms/hhs.gov/NPPES/ It takes approximately 20 minutes to apply online and you normally have your NPI number within in a matter of hours at best to a few days at worst. 13 Current copy of a federal or state license document with signature and photograph (state driver's license or passport). 14 Continuing Medical Education (CME). Please attach documentation completed within the last two (2) years. 15 PPD (Tuberculosis Status) Please attach results of PPD testing within the last twelve (12) months. 16 Expedited Credentialing Policy Signature Page, signed and dated. 17 Infection Control Training, please complete online at: https://www.emoryhealthcare.org/app/providerassessment/module/ You must complete all four (4) portions of the infection control module before you are considered complete. 18 Emory Job Description signed by Primary Sponsor. 19 Clinical Performance Evaluation.

Physicians Reappointment  Documentation Required 1 Georgia Uniform Recredentialing Application Part 1. (Please contact our office for a pre-populated application if you have not already received for your reappointment) 2 Emory Healthcare Recredentialing Application Part 2. (Please contact our office for a pre-populated application if you have not already received for your reappointment) 3 All disclosure questions have been answered with explanations provided for a "Yes" response. 4 Release/Attestation/Signature page has been signed (original signature) and dated. 5 New privilege form completed (Please select the appropriate privilege form) 6 Copy of current Georgia Medical License (Wallet Size). 7 Copy of current DEA certificate. 8 Current CV (month/year format) with the last five (5) years of work history (include explanations for any six (6) month gap in experience or training. 9 Two (2) professional references. 10 Schedule B for explanation of malpractice claims history completed, if applicable. 11 Malpractice Insurance Certificate/Face Sheet (Non-Emory Faculty only). 12 Current copy of a federal or state license document with signature and photograph (State driver's license or passport). 13 Continuing Medical Education (CME). Forty (40) CME's have been documented and/or submitted. 14 Expedited Credentialing Policy Signature Page, signed and dated. 15 EJCH Only: PPD (Tuberculosis status) please attach results of PPD testing within the last twelve (12) months. 16 EJCH Only: Confidentially statement 17 EJCH Only: Reflex testing 18 Infection Control Training. Please complete online at: https://www.emoryhealthcare.org/app/providerassessment/module/ 19 Performance Evaluation for The Emory Clinic (TEC).

Allied Health Professional Reappointment Documents Required 1 Georgia Uniform Recredentialing Application Part 1. (Please contact our office for a pre-populated application if you have not already received for your reappointment. 2 Emory Healthcare Recredentialing Application Part 2. (Please contact our office for a pre-populated application if you have not already received for your reappointment. 3 All disclosure questions have been answered with explanations provided for any "Yes" responses. 4 Release/Attestation/Signature page has been signed (Original signature) and dated. 5 New Privilege form has been completed (Please select the appropriate privilege form) signed by the Primary Sponsor. 6 Copy of current Georgia Medical License (Wallet Size). 7 Copy of current DEA certificate enclosed. 8 Current CV (month/year) format with the last five (5) years of work history (include explanations for any six (6) month gap in experience or training. 9 Two (2) professional references. 10 Schedule B for explanation of malpractice claims history completed, if applicable. 11 Malpractice Insurance Certificate/Face Sheet (Non-Emory Faculty only). 12 Current copy of a federal or state license document with signature and photograph (State driver's license or passport). 13 Continuing Medical Education (CME). Please attach documentation of at least 40 CME credits. 14 Expedited Credentialing Policy Signature page, signed and dated. 15 Performance Evaluation for The Emory Clinic (TEC) faculty. 16 Infection Control Training. Please complete online at: https://emoryhealthcare.org/app/providerassessment/module/