Recruitment Forms
The following information will be required in order to complete the credentialing and privileging process:
- Peer References (3) (MS Word file)
- Hospital Verification Form (MS Word file)
- Standardized Credentialing Form (MS Word file)
- Current CV (it must be dated)
- Missouri license (online application)
- BNDD license (online application)
- DEA license (online application)
- Medical school diploma
- Residency completion certificate
- ECFMG (Educational Commission for Foreign Medical Graduates)
- Board certification
- Privileges Application with University Hospital and Clinics
- Privilege Delineation Form
- Proof of 25 CME credits for each of the last two calendar years
- Access and Confidentiality Agreement
- Medicare Penalty Statement
- Tricare Penalty Statement
- Staff Health form on up-to-date immunizations
- Proof of faculty screening by Staff Health
- Pharmacy signature card
- Conscious sedation privilege form
- Collaborative Practice Agreements (if applicable)
