Medical Staff/Allied Health Professional Credentialing Pre-Application

I hereby consent to the exchange of information and documents relating to my credentials and qualifications between Community Hospital of the Monterey Peninsula and any licensing authorities, businesses, and/or individuals acting as their agents, for the purpose of evaluating this preliminary inquiry regarding my eligibility to provide medical services to this facility.  I further consent to the release, disclosure, inspection, and reproduction of any such information and documents as becomes necessary during the evaluation process with regard to my inquiry.

I hereby affirm that the information I have submitted to Community Hospital of the Monterey Peninsula, and any addenda thereto (including my curriculum vitae), are true, current, correct, and complete to the best of my knowledge and belief, and are furnished in good faith.  I understand that material omissions or misrepresentations may result in denial of my application. 

Please input the following information:
Please check if you accept:
Medical Staff Status Categories

Please select your desired category.
Would you like to apply for privileges at Westland House (long term care facility)?
Please submit a current copy of your curriculum vitae.