Please complete the below information form to request an application with HHS Full Legal Name/Degree (title) * Date of Birth * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year1934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006 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
