PinnacleHealth Independent Physician
Thank you for your interest in practicing at PinnacleHealth Hospitals. The following documents will be necessary to complete
your Medical Staff Credentialing. Please note that these processes take at a minimum 2-3 months to complete.
To complete the additional required online forms as outlined below, please use the following link:
http://www.pinnaclehealth.org/for-employees-and-professionals/for-medical-professionals/physician-and-practitionerservices/physician-and-allied-health-staff-applications
Please do not hesitate to contact me with any questions.
Heather Johnson, Manager of Physician & Practitioner Services
Office: 717-231-8302
Cell: 717-476-0893
Email: hjohnson@pinnaclehealth.org
PENNSYLVANIA STANDARD APPLICATION
PINNACLEHEALTH SUPPLEMENTAL APPLICATION
CV IN MONTH/YEAR FORMAT (VERY IMPORTANT TO HAVE BEGINNING & ENDING MONTHS/YEAR ON CV)
WRITTEN EXPLANATION FOR “ANY” WORK GAP One month or greater (since matriculation from medical school)
DIPLOMA(S) (please include Bachelor, Master and/or Doctorates); official transcripts are acceptable if you don’t have a
copy of your diploma
RESIDENCY CERTIFICATE
FELLOWSHIP CERTIFICATE ̶ if applicable
ECFMG CERTIFICATE (FOR FOREIGN MEDICAL GRADS ̶ if applicable
SOCIAL SECURITY CARD
PA STATE BOARD OF MEDICINE LICENSE https://www.mylicense.state.pa.us/
DEA (with PA address; may use practice location address) http://www.deadiversion.usdoj.gov/drugreg/process.htm
DRIVER’S LICENSE
BOARD CERTIFICATION ̶ if applicable
MALPRACTICE FACE SHEET (and/or Current Certificate of Insurance) ̶ These are available from the Risk
Management offices at your Current facility or educational institution.
MALPRACTICE FACE SHEETS FOR THE PRIOR 5 YEARS ̶ These are available from the Risk Management offices
at your Current facility or educational institution.
Privilege Form ̶ if applicable
Procedure Logs ̶ if applicable
BLS, ACLS, ALSO, PALS, ATLS, NALS and CPR Certificates ̶ if applicable
FBI Clearance, Pennsylvania State Criminal Record Check, and PA Child Abuse Clearance
Marriage certificate if you have had a recent name change within the last 6 months
Attend onsite orientation – This will be schedule by the Physician & Practitioner Services Department.
Photo taken at interview or emailed to us
$300.00 application fee