For INITIAL APPLICATIONS

For physicians:

1. Part I of the Uniform Practitioner Application. Form number 1002
2. Part II of the Emory Healthcare Initial Application. Form number 1003
3. Curriculum vitae, including past 5 year work history in a month/year format.
4. Explanation of any 6 months gap in experience or training.
5. Copy of Current Georgia Medical, Dental or Podiatric License.
6. Copy of Current DEA Registration Certificate.
7. Copy of Current Professional Liability Face Sheet, not less than $1M/$3M Coverage. (If not employed by the Emory School of Medicine).
8. Copy or documentation of Board Certifications or status.
9. Work History Form, if curriculum vitae do not meet formatting guidelines. Form number 1013
10. Completed clinical privileges form, if applicable.
11. Documentation of procedures performed, if applicable.

Physician Assistants or Anesthesiology Assistants

1. Completed Application signed by Primary Sponsor and Physician Assistant. Form number 1005
2. Curriculum vitae, including past 5 year work history in a month/year format.
3. Explanation of any 6 months gap in experience or training.
4. Completed Clinical Performance Evaluation. Form number 1007
5. Copy of Current Georgia Medical License.
6. Copy of Current DEA Registration Certificate, if applicable.
7. Copy of Current Professional Liability Face Sheet, not less than $1M/$3M Coverage. (If not employed by the Emory School of Medicine.)
8. Completed Privileges form signed by Primary Sponsor.
9. Emory Job Description signed by Primary Sponsor.

Dental, Podiatric, Scientific or Allied Health Professional, other than Physicians Assistants.

1. Application for Appointment. Form number 1005
2. Curriculum vitae, including past 5 year work history in a month/year format.
3. Explanation of any 6 months gap in experience or training.
4. Copy of Current Georgia Professional License.
5. Copy of Current DEA Registration Certificate.
6. Copy of Current Professional Liability Face Sheet, not less than $1M/$3M Coverage. (If not employed by the Emory School of Medicine.)
7. Work History Form, if curriculum vitae do not meet formatting guidelines. Form number 1013
8. Completed privileges form, if applicable.
9. Documentation of procedures performed, if applicable.

For REAPPOINTMENT APPLICATIONS

All physicians:

1. Part I of the Uniform Recredentialing Application. Form number 1004
2. Part II of the Emory Healthcare Reappointment Application. (Please contact System Credentialing for Part II. It is specific to each provider and is accompanied by your current clinical privileges form.)
3. Curriculum vitae, including past 5 year work history in a month/year format.
4. Explanation of any 6 months gap in experience or training.
5. Copy of Current Georgia Medical License.
6. Copy of Current DEA Registration Certificate.
7. Copy of Current Professional Liability Face Sheet, not less than $1M/$3M Coverage. (If not employed by the Emory School of Medicine.)
8. Copy or documentation of Board Certifications or status, if changed since last appointment.
9. Work History Form, if curriculum vitae do not meet formatting guidelines. Form number 1013
10. Completed privileges form, if applicable.
11. Documentation of procedures performed, if applicable.
12. Documentation of at least 40 continuing medical education (CME) credits.

Scientific, Dental, Podiatric and Allied Health Professionals, other than Physician Assistants:

1. Completed Application (Please contact System Credentialing for this application.  It is specific to each provider.)
2. Curriculum vitae, including past 5 year work history in a month/year format.
3. Explanation of any 6 months gap in experience or training.
4. Copy of Current Georgia Professional License.
5. Copy of Current DEA Registration Certificate.
6. Copy or documentation of Board Certifications or status, if changed since last appointment.
7. Work History Form, if curriculum vitae do not meet formatting guidelines. Form number 1013
8. Completed privileges form, if applicable.
9. Documentation of at least 40 continuing medical education (CME) credits.

For Physician Assistants or Anesthesiology Assistants:

1. Completed Application signed by Primary Sponsor and Physician Assistant. (Please contact System Credentialing for this application. It is specific to each provider.) 
2. Curriculum vitae, including past 5 year work history in a month/year format.
3. Explanation of any 6 months gap in experience or training.
4. Copy of Current Georgia Medical License.
5. Copy of Current DEA Registration Certificate, if applicable.
6. Copy of Current Professional Liability Face Sheet, not less than $1M/$3M Coverage.  (If not employed by the Emory School of Medicine.)
7. Completed privileges form signed by Primary Sponsor.
8. Biennial Quality Review Form completed by Primary Sponsor. Form number 1012
9. Documentation of at least 40 continuing medical education (CME) credits. (At least 3 CMEs covering pharmacology, if granted prescriptive authority.)