New Practitioner Notice | Medical Staff Services

Applicant Contact Information

*First Name :

*Last Name :

Middle :

Suffix :

*Degree/Title :

*Contact Email :

Secondary Email :

Applicant Employment Information

*Faculty appointment ? Yes No

If faculty appointment, Paid or Voluntary ? Paid Voluntary

Academic Department :

*Desired effective date :

*State employed ? Yes No

Select Employer/Leaser :

Other Employer :

*Clinical Department :

Clinical Division :

Clinical Section :

*Will this person be 100% remote work ? Yes No

*Primary Site :

Other Primary Site :

Applicant Patient Care and Insurance Information

*Primary Patient Care Address :

Primary Care Mailing Address (if different):

*Supervising/Collaborating Physician Name (enter N/A for physicians, dentists, and podiatrists):

For Medical Staff, who is providing malpractice liability insurance coverage ?

If a physician, dentist, or podiatrist, who is paying the application fee ?

Submitter Information

*Your First Name :

*Your Last Name :

*Your Email :

*Your Phone :

Upstate Contact Information

Upstate Contact First Name :

Upstate Contact Last Name :

Upstate Contact Email :

Upstate Contact Phone :

Documents

Document 1 :

Document 2 :

Document 3 :

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