Centralized Credentialing Services - A Credentialing Verification Organization
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Application for Appointment

INSTRUCTIONS


1. Physicians, APNs, PAs complete and sign this Application

(For physicians, APNs, PAs only Click here for an addendum to the TSCA form)

  • Release Authorization(s) (signed & dated)

    2. Attach copies of the following documents:

  • Delineation of Privileges, upon request.
  • CME Form (Use this Form)
  • Signature Card - Pharmacy & Medical Records Form (Use this Form)
  • Medicare/Medicaid Form (Use this Form)
  • Copies of all state medical license(s)
  • DPS certificate, if applicable
  • DEA certificate, if applicable
  • Certificate(s) of Malpractice Insurance FOR PAST 5-10 YRS
  • Proof of Board Certification, if applicable
  • Curriculum Vitae, including complete work history
  • ECFMG certification, if applicable
  • ACLS/CPR Certificate, if applicable
  • Procedure Log for previous 24 months, if applicable

    3. Return the completed Application and copies of the documents specified in item #2 to:

    Centralized Credentialing Services
    P. O. Box 6307
    Tyler, TX 75711-6307

    4. If you have questions or need assistance regarding this package, please contact: Anita Odom (903/579-3948)

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    Centralized Credentialing Services
    P.O. Box 6307
    Tyler, TX 75711-6307
    800-477-2287 ext. 83948


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