Providence

Hospital
Live Smart. Live Healthy. CREDENTIALING FORM

Name of Applicant Department Specialty

CATEGORY APPLIED:

□ Active Consultant □ Hospitalist □ Industrial Medicine

□ Visiting Consultant □ Associate Consultant □ ER Consultant

REQUIREMENTS:

□ Letter of application □ Philippine Medical Association (PMA) ID

□ Accomplished application form □ Philippine Dental Association (PDA) ID

□ Recent photo (2x2) □ Philhealth ID (Expiration: _____________________________)

□ Medical School Diploma □ Photocopy of updated PTR

□ Physician Licensure Board Certificate □ S2 license (for all hospitalists and the following specialties:
Emergency Medicine, Anesthesia and Pain Management,
□ Certificate of Completion of Residency training Medical Oncology, Cardiology, Gastroenterology, Neurology,
Geriatrics, and Pulmonary Medicine, Critical Care)
□ Certificate of Completion of Sub-specialty / Fellowship
training and other certifications for specialized procedures □ Photocopy of updated Life Support Certification

□ Specialty and Sub-specialty Board Certificate □ TIN #

□ PRC ID (Expiration: _______________________________)

REQUIREMENTS:

□ Application Approved □ Application Declined

__________________________________ __________________________________
Section Head Department Chairman

LYSANDER P. RAGODON, MD, FPCP, MHSA DAVE B. TAN, MD

Medical Director President and CEO

Date of Appointment: ___________________________

□ Informed
□ Bizbox
□ List of Consultant
□ Letter of Appointment
 Date applied: ________________ Control Number: ________________

Providence
Hospital Recent
Live Smart. Live Healthy. Photo

MEDICAL STAFF APPLICATION FORM

Please print and write legibly

Specialty: Subspecialty:

Name: Home No. :

(First Name) (Middle Name) (Last Name) (Nickname)

Present Address: Office No.:

Permanent Address: Mobile No.:

Age: Gender: Civil Status: Place of Birth: Religion:

Date of Birth: TIN # Philhealth #(validity) Email address:

PRC # S2 # (validity) PMA # Referred by:

EDUCATIONAL / TRAINING BACKGROUND

Name of Institution / Address
Pls. use registered name upon graduation or certification for verification purpose
From To
Pre-Medical Education

Medical Education (Doctor of Medicine)

Internship Hospital

Residency Training

Fellowship Training

Additional Training

CERTIFICATION
Date Awarded
Philippine Board of Medicine

Specialty Board Certification (Diplomate)

Sub Specialty (Diplomate) Board Certification

Basic Life Support

ACLS / NALS

Additional certification / s:
 ACADEMIC EXPERIENCE
Institution / Address Current and Past Position / Academic Rank Inclusive Dates

CURRENT MEDICAL STAFF MEMBERSHIP IN OTHER HOSPITALS / CLINICS

Institution / Address Position Date of Affiliation

PAST POSITIONS IN OTHER HOSPITALS / CLINICS

Institution / Address Position Date of Affiliation

REFERENCE
( Those who ca vouch for your moral character & integrity, include the Department Head or the Training Officer where you graduated from Residenct / Fellowship / the Medical
Director / Department Chairman where you are currently affiliated / were last connected with )

Name Designation Institution Contact Number

Person to notify in case of emergency or illness ( Indicate relationship, address & telephone no. )

Name Relationship Address Contact Number

RECOMMENDATION:

□ Application Approved □ Application Declined

__________________________________ __________________________________ __________________________________

Section Head Department Chairman Chairman Credential Committee

RECOMMENDATION:

□ Application Approved □ Application Declined

__________________________________ __________________________________ __________________________________

Assistant Medical Director Medical Director President and CEO