Initial Application App Central Request Form

Centralized Credentialing Services
1 Ford Place - 2E
Detroit, MI 48202
(313) 874-4689
hfhccs@hfhs.org

* Asterisk indicates required field.

Applicant requesting privileges or affiliation at




check all hospitals applying for
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If the applicant does currently have privileges at an HFHS hospital please choose which one or ones




Application Request Date
(mm/dd/yyyy)
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Name of the person you are submitting the request on behalf of
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i.e.: M.D., P.A., Ph.D.
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(mm/dd/yyyy)
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If yes please choose which groups


(mm/dd/yyyy)
(mm/dd/yyyy)
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Employed practitioners only
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*
employed practitioners only
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employed practitioners only
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For HFHS Recruiters Only
Check those that are applicable

Inform the applicant that an application will be sent via email from appcentral@cactussoftware.com within two business days after receipt of this form
 
Contact centralized credentialing

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