Bayview Department of Medicine Provider Information Sheet

Provider Information Sheet

** A Confirmation will be sent to your email address **
If you do NOT receive this email, it indicates that there was an error and you must resend.

Instructions to Division: Complete this form for EVERY new (or outgoing) provider that will bill for clinical services. This is in addition to the forms you must complete for hospital credentialing and privileges. Note: Fields marked with "«" are REQUIRED.

Form Submitted by «

Contact Email «

Contact Email Again «

Contact Phone «

Provider First Name «

Provider Last Name «

Provider Phone

Provider Email

Division «

If Other, please specify

Home Address «

Mailing Address (if different from above)

START or END Date (MM/DD/YYYY) «

Billing Area(s) (List all) «

Primary Campus Affiliation «

Status

MD/Attending

Nurse Practitioner

Physician Assistant

Clinical Fellow

Employer «

If Other, please specify

Mark all sites where they will practice

JH Bayview Medical Center

Johns Hopkins Hospital

JH at Greenspring Station

JH at White Marsh

If Other, please specify

Fields marked with « are required.

Bayview Department of Medicine Provider Information Sheet

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