Please complete the below information form to request an application with HHS Full Legal Name/Degree (title) * Date of Birth * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year1935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007 Year Cell Phone * Preferred Email Address * NPI * Practice/Office * Requesting TeleMed Only? * No Yes Name of Credentialing Contact * Email of Credentialing Contact * Supervising Phyisican (if applicable) The Credentialing process can take up to 60 days from the day a complete application is submitted. If you have requested a start date that requires expedited credentialing, please provide information regarding this request below. Comments Please select all facilities to which you will be applying for Facilities Applying * Hillcrest Medical Center Hillcrest Hospital South Hillcrest Hospital Claremore Hillcrest Hospital Pryor Hillcrest Hospital Cushing Hillcrest Hospital Henryetta Bailey Medical Center Tulsa Spine and Specialty Hospital Submit
