Hospital Privileges for Providers

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 NameLast Name
Provider's CPR Email Address
example@cprecovery.com
Are you requesting hospital privileges be added or terminated?
HV = High Volume Hospitals

LV = Low Volume Hospitals
List of Hospitals for the Provider
Termination Date

MonthDayYear
Date
Regional Director
Your CPR Email Address
example@cprecovery.com
Signature

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Date

MonthDayYear
Date
Should be Empty: