Hospital Privileges for Providers
Note: The Hospital Privilege Process will not start until the necessary Credentialing steps have been completed by the Provider.
Name of Provider (CPR Employee)
*
First Name
Last Name
Provider's CPR Email Address
*
example@cprecovery.com
Are you requesting hospital privileges be added or terminated?
*
Added
Terminated
HV = High Volume Hospitals
LV = Low Volume Hospitals
List of Hospitals for the Provider
*
(HV) Banner Desert/ Cardon
(LV) Banner Baywood
(HV) Banner Estrella
(LV) Banner Boswell
(HV) Banner Thunderbird
(LV) Banner Del Webb
(HV) Banner University Medical Center
(LV) Banner Gateway
(HV) Banner Casa Grande
(LV) Banner Goldfield Medical Center
(LV) Banner Heart
(LV) Banner Ironwood
(LV) Banner Ocotillo Medical Center
Termination Date
*
-
Month
-
Day
Year
Date
Regional Director
*
Please Select
Jesse Hash
Jennifer Willis
Lisa Stegemoller
Pattie O'Connor
Your CPR Email Address
*
example@cprecovery.com
Signature
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: