Sentara Hospitals Medical Staff Application Request Form

Please use this form to request an application for all of the Sentara hospitals medical staffs to which you are applying. You and your designee (if you identify a person who will assist you in completing your application) will receive a link to our electronic application. You will want to bookmark that link. When you click on that link for the first time, enter your e mail address and click on the First Time Login button to create your password. If you do not begin completing your application within 8 hours of establishing your password, you will need to request a new password by clicking on “Forgot My Password.”

Please provide the information requested below so that we may create your application. You may expect to receive an e mail with a link to our electronic application within 2 working days of submission of this request.
*Denotes required information
*Please indicate the Sentara Hospital Medical Staff to which you are applying: (Select all that apply - Hold down the Ctrl button to make more than one selection)
Applicant Information
*Last Name
*First Name
*Middle Name
*Date of Birth
NPI Number
*E Mail Address
*Applicant Type (MD, DO, etc.)
*Residency Completed
Fellowship Completed
Allied Health Professionals
If you are an Allied Health Professional, please provide the name(s) of your sponsoring or supervising physician(s).
Group Information
Group Tax ID Number
*Practice Name
Effective Date at the Practice (i.e. MM/DD/YYYY)
Credentialing Support
Contact Name (person assisting you in completing the application)
Contact Phone Number xxx-xxx-xxxx
Contact E Mail Address (must be different from the applicant's e mail address)
Please provide the information requested below for any additional individuals who may be providing assistance to you in completing your application. If there are no others, skip this section and complete the following sections.
Name of second person assisting you in completing the application
Contact Phone Number xxx-xxx-xxxx
Contact E Mail Address (must be different from the applicant’s email address and from others assisting the applicant)
Name of third person assisting you in completing the application
Contact Phone Number xxx-xxx-xxxx
Contact E Mail Address (must be different from the applicant’s e mail address and from others assisting the applicant)
Locum Tenens Applicants
If you are applying to work at Sentara through a locum tenens agency, please provide the information requested below.
Name of locum tenens agency
Name of contact person at locums agency assisting you with your application
Contact Phone Number xxx-xxx-xxxx
Contact E Mail Address (must be different from the applicant’s email address)
Board Certification Information
If No, indicate the year residency/ or fellowship was completed
*If the applicant is a physician, oral surgeon or podiatrist, is the applicant certified by a specialty board recognized by the American Board of Medical Specialties or the American Osteopathic Association, or by the American Board of Podiatric Surgery or the American Board of Oral and Maxillofacial Surgery?
Background Information
1. Has the applicant ever been convicted of or entered a plea of guilty or no contest to any felony or any misdemeanor relating to controlled substances, illegal drugs, insurance or health care fraud or abuse, or violence?
2. Has the applicant ever been excluded or precluded from participation in Medicare, Medicaid or other federal or state governmental healthcare programs?
3. Has the applicant ever been convicted of Medicare, Medicaid or any other governmental or third party payer programs of fraud or program abuse or has the applicant paid civil money penalties for same?
4. Has the applicant ever had his or her Medical Staff appointment or clinical privileges denied, revoked, relinquished or terminated by any healthcare facility or health plan for reasons related to clinical competence or professional conduct?
5. Has the applicant ever had a license to practice revoked or suspended by any state licensing agency?
For additional information or questions about an application, please contact us at:
       Sentara Hospitals Credentialing Office
       600 Gresham Drive, 7B
       Norfolk, VA 23507
       757-388-6175
       Email: hospitalcredentials@sentara.com