How to submit an application to the MultiCare Health System Credentialing Office
Request an Application from the MultiCare Health System Credentialing Office
All Applicants: To request an initial application, add a facility or request additional privileges, complete the appropriate application request form, using the Non-Employed or Employed link below:
Non-Employed Application Request Form Employed Application Request Form
A Washington Practitioners Application packet or Additional membership/privileges application and privilege form(s) will be emailed directly to the email address you provide on the form.
Initial Credentialing Packet includes:
- WPA (Washington Practitioners Application)
- Privilege form(s)
- MultiCare Health System Authorization and Release
- Attestation Questionnaire Form
- Immunization form
- Medicare/TriCare Physician Acknowledgement Statement
- Membership/privileges Hospital Request and Orientation Information
- Provider Handbook and Problem List Attestation
- DEA Attestation (if applicable)
- Application Fee Payment Form
Contact information for all new and existing credentialed providers:
- MHS Medical Staff Office – Phone: 253-403-1085
- MHS Medical Staff Office – Fax: 253-403-4870
- Credentialing email address: [email protected]
Name, Address, and/or Contact Info Changes and Resignations
If you are currently a practitioner on staff at a MultiCare Health System (MHS) entity(ies), please use the Practitioner Change Form to notify the Credentialing office of any changes to your personal contact information, specifically; legal name changes, home or office address, phone, fax, cell or beeper information that can assist us in ensuring that we have the most current and accurate information in our system to better serve you.
Note: This form can also be used as notification for Resignation from any MHS facility.
- Complete the Practitioner Change Form
- Save as your own document and submit electronically or print and submit a paper copy to:
MultiCare Health System
315 Martin Luther King Jr Way
M/S: 315-C3-CRD
Tacoma, WA 98405
Email: [email protected]
Fax: 253-403-4870