Centralized Verification Office
3176 S Denver Wy
Boise ID 83705
Telephone: (208) 381-8745
Fax: (208) 381-8786
Email: cvo@slhs.org
APPLICATION REQUEST FORM
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This form must be typed
Please complete and email to: cvo@slhs.org
REQUESTED BY
Facility:
BrightPath Network
Elmore
Jerome
Life Care Centers of TV
Magic Valley
McCall
Requesting Facility Coordinator:
Today’s Date:
Tammy Engum
North Canyon Medical Center
Select Network
Treasure Valley
Weiser
Wood River
Is this going to be a St. Luke’s
employed provider?
PRACTITIONER INFORMATION
Practitioner (Legal) Name:
Title:
MD
DPM
DMD
NP
Other:
Gender:
DO
DDS
PA
CRNA
Male
Female
Anticipated Start Date:
NPI Number:
Specialty:
Mailing Address:
Phone:
PROVIDER Email address:
ADMIN Email address:
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Primary Practice Name/DBA:
Primary Practice Address:
Primary Practice Phone:
Primary Practice Tax ID Number (TIN):
Primary Practice Fax:
Board Certification Status:
Certified
Admissible*
Not Board Certified*
*If not certified or admissible, do you intend to become certified?
Yes
No
CLINICAL PRIVILEGE FORMS TO SEND
Please send the following specialty-specific clinical privilege form(s)
MEDICAL/DENTAL/PODIATRY PROVIDERS:
Allergy & Immunology
Cardiovascular Medicine
Developmental Behavioral Pediatrics
Endocrinology
General Surgery
Internal Medicine
Medical Oncology
Neurological Surgery
Occupational Medicine
Orthopedic Surgery
Pathology
Pediatric Gastroenterology
Anesthesiology
Dentistry
Electrophysiology
Family Medicine
Hyperbaric & Wound Medicine
Interventional Cardiology
Neonatal/Perinatal Medicine
Neurology
Ophthalmology
Otolaryngology
Pediatric Cardiology
Pediatric Hematology/Oncology
Pediatric Neurology
Pediatrics
Podiatry
Pulmonary Medicine (Telemed)
Sleep Medicine
Pediatric Pulmonary Medicine
Physical Medicine & Rehab
Psychiatry
Radiation Oncology
Surgery Assist Only
Urology
Vascular Surgery
ALLIED HEALTH PROVIDERS:
Acupuncture
Cryosurgery Technician
Lithotripsy Technician
Nurse Anesthetist (CRNA)
Ocularist
Physician Assistant
Scribe
RESIDENT PARAMETERS:
Emergency Medicine
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Audiologist
Dental Assistant
Massage Therapist
Certified Nurse Midwife
Pathologist Assistant
Private Surgical Scrub
Other:
Family Medicine
Cardiology (Telemed)
Dermatology
Emergency Medicine
Gastroenterology
Infectious Disease
Medical Imaging
Nephrology
Obstetric/Gynecology
Oral & Maxiollofacial
Pain Medicine
Pediatric Critical Care
Pediatric Infectious
Disease
Pediatric Surgery
Plastic Surgery
Pulmonary Medicine
Rheumatology
Thoracic & Cardiac
Surgery
Other:
Cardiac Perfusionist
Laser Technician
Non-Physician First
Assistant
Nurse Practitioner
Physical Therapist
Psychologist
Internal Medicine
Psychiatry
ADDITIONAL PRIVILEGE FORMS:
Conscious Sedation
Clinic Privileges:
NOTES/COMMENTS:
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Other:
EICU Clinical Privileges
Other: