Dear Provider, Thank you for your recent inquiry in credentialing ...

Dear Provider,
Thank you for your recent inquiry in credentialing with Emory Healthcare – Emory Johns Creek
Hospital.
Emory Credentialing has launched new on-line credentialing software. As part of the new process, ALL initial
appointment applicants, modifications, and reappointment applicants must now complete the online version of the
application. You will find a credentialing request form attached. Please complete this form and return it to the
Medical Staff Office (MSO). Once your form is entered into the credentialing system, you will be emailed a link to
complete the on-line application.
Creation of a user ID and password will be required. Please note: a unique e-mail address will be required for EACH
applicant, as the new system does not allow for multiple applicants/providers to have the same e-mail address.
(Office staff/managers: please be aware that this needs to be the physician’s email addresses (not your own) and that
all notifications/reminders for re-credentialing/medical staff information will be sent to this email address. If you are
the representative that completes the credentialing process for your providers, you will need to make sure you are
forwarded any reminders/information or have access to this email account).
In addition to the electronic application, the following are still required and needed for our records. Please fax these
documents to Larry “Ken” Davis at 404.778.5212
A Current Government Issued ID
Schedule A from the Georgia Uniform Application (will be provided in the electronic application)
Schedule C from the Georgia Uniform Application (will be provided in the electronic application)
Proof of malpractice coverage
For credentialing approval, please allow 90 days from the date the completed application and all required
materials are submitted.
If you have any further questions, please do not hesitate to contact us. Thanks again! We look forward to
working with you soon!
Sincerely,
Lisa Norton
Director, Medical Staff Services – Emory Johns Creek Hospital
Office: 678.474.7036; Fax: 678.474.7034
Lisa.Norton@emoryhealthcare.org
Andra Conway
Medical Staff Coordinator – Emory Johns Creek Hospital
Office: 678.474.7024; Fax: 678.474.7025
Andra.Conway@emoryhealthcare.org
Larry “Ken” Davis
Credentialing Verification Specialist (Emory Johns Creek Hospital - Community Physicians)
Office: 404.778.5212; Fax 404.778.3008
Larry.Davis@emoryhealthcare.org

REQUEST FOR APPLICATION / CREDENTIALING FORM
ALL INFORMATION IS REQUIRED IF APPLICABLE TO APPLICANT
DATE OF REQUEST ____\ ____ \ ____
ESTIMATED START DATE ____\ ____ \ ____
CREDENTIALING REQUEST (SELECT ONE):
New Hire/Initial Request Adding a Facility
ENTITY REQUESTING (*Please indicate all entities for which you are requesting privileges)
Emory Johns Creek Hospital
Emory University Hospital (Emory Faculty Only)
Emory University Hospital Midtown
Saint Joseph’s Hospital
Wesley Woods Geriatric Hospital
Wesley Woods Long Term Care
Wesley Woods Long Term Hospital
CATEGORY REQUESTING - FOR EJCH ONLY (*See category definitions attached)
Active Courtesy Affiliate
PROVIDER FULL NAME: ______________________________________________________________________
PROVIDER TYPE/TITLE (MD, DO, PA, etc): _________________ DATE OF BIRTH: __________________
SSN# (required): _________ - __________ - _________
NPI #: ______________________________________
GA LICENSE #: ____________________________
DEA #: _________________________________________
EMAIL ADDRESS: ____________________________________________________________________________
*Invitation will be sent to this email address to complete the application
DEPARTMENT/ SPECIALTY: __________________________________________________________________
BOARD CERTIFICATION/QUALIFICATION(Physician Only): ____________________________________
COVERING PROVIDER(S) (required – must be a current medical staff member at each facility applying):
______________________________________________________________________________________________
SPONSORING PROVIDER(S) (Allied Health Only - required): ______________________________________
Have you ever been granted or applied for clinical privileges at any Emory Healthcare entity)? Yes No
Is the provider’s patient load more than 50% pediatrics (17 years and younger)? Yes No
Are you joining an existing Practice? Yes No
PRIMARY PRACTICE NAME: _________________________________________________________
ADDRESS: __________________________________________________________________________
PHONE #: _____________________________
CELL #: _______________________________
FAX #: _____________________________________
TIN#: ______________________________________
CREDENTIALING CONTACT NAME/TITLE: ___________________________________________
PHONE #: ____________________________
EMAIL: _____________________________________
Please return via fax or email (no cover sheet necessary - confidential/secured fax & email):
Lisa Norton
Andra Conway
Fax: 678.474.7034 Fax 678.474.7025
Email: Lisa.Norton@emoryhealthcare.org Email: Andra.Conway@emoryhealthcare.org
You should receive an email with a link to the on-line application within 3 business days.
For credentialing approval, please allow 90 days from the date that the completed application is submitted.

MEDICAL STAFF STATUS REQUESTED FOR
EMORY JOHNS CREEK HOSPITAL ONLY
(Please check one)
Please Note: All category requests must be approved by the Department Chair, Credentials Committee, Medical
Executive Committee, and Advisory Board.
____ ACTIVE The active staff category shall consist of Practitioners who actively support the Medical
Staff and the Hospital by contributing to efforts to fulfill Medical Staff functions. All active category
practitioners are required to take Emergency Call Coverage, if a formal schedule is created for their
specialty. To qualify for the Active Staff category, the Medical Staff member may maintain more than
twenty­four (24) cases per reappointment period, twenty­four (24) months of accumulated data,
defined as management of patients and/or performance of inpatient/outpatient operative and other
procedures.
____ COURTESY The Courtesy staff category shall consist of practitioners who meet the basic
qualifications for staff membership and who may only occasionally provide hospital services for
patients, due to practicing primarily at another hospital or in an office­based specialty, or other
reasons, but who wish to remain affiliated with the Hospital for consultation, call coverage, referral of
patients, or other patient care purposes. To qualify for the Courtesy Staff category, the Medical Staff
member may maintain up to twenty­four (24) cases per reappointment period, twenty­four (24)
months of accumulated data, defined as management of patients and/or performance of
inpatient/outpatient operative and other procedures. Courtesy Medical Staff members who exceed
the patient care activity requirement for the management of patients or performance of inpatient/
outpatient operative and other procedures may be transferred to the Active Staff category.
____ AFFILIATE The Affiliate staff category shall consist of practitioners who do not practice in the
Hospital but still desire to maintain medical staff appointment to provide continuity of care to their
patients or to satisfy a criterion of medical staff membership and access to in­network hospital
services that may be required for participation in managed care organization panel(s). The Affiliate
Staff category is a membership­only category of the Medical Staff with no clinical privileges, and
limited medical staff responsibilities and prerogatives. As Members of the Medical Staff, Affiliate Staff
shall be fully credentialed and shall be granted membership based on a recommendation by the
Medical Staff, with approval by the Governing Body. Since no clinical privileges are granted, Affiliate
Staff shall not be subject to the requirements for focused professional practice evaluation or ongoing
professional practice evaluation. Members of the Affiliate staff shall be ONLY able to: visit patients
with full access to medical charts, records, radiographs, tests as completed on his/her referred
patients; attend meetings of the staff and the department of which he/she is an appointee and any
staff or hospital education programs; and be eligible for programs that are offered by the Office of
Physician Services.
You should receive an email with a link to the on-line application within 3 business days.
For credentialing approval, please allow 90 days from the date that the completed application is submitted.