Surgeon Credentialing/Re-credentialingCredentialing Information for Surgeons
Thank you for your interest in applying to the Black Canyon Surgical Center. In order to meet the requirements of the State/Medicare licensure, please see the required credentialing application material necessary for practitioners who wish to practice at the center. Please complete the credentialing application attached and include all items listed on the checklist below in your credentialing application to the Center.
It is important that this first step of the process is done as soon as possible. When completing the Delineation of Clinical Privileges form(s), it is also very important that you do not just line through the procedures for which you want to be credentialed; instead please make a check in the yes or no column for each individual procedure. In addition, please include full addresses and phone numbers for all medical references and hospital affiliations. Please return all forms to:
Dan Soderlind, Black Canyon Surgical Center, 611 East Star Court, Suite C, Montrose, CO 81401.
****According to the Medical Staff Bylaws, any doctor who wishes to list a peer reference from within his/her practice may only list two doctors from within. Please be conscious of this upon completion of the reference section on page 15 of the Colorado Uniform Credentialing Application and remember to list a third reference from outside of the practice.
Once we have a completed packet, we will be able to follow up on the verification that is required to satisfy the licensing agencies. We will also query the National Practitioner Data Bank and the AMA.
A completed packet will include:
• Colorado Uniform Credentialing Application
• Application for Appointment – Declarations (1 page)
• Current License
• DEA Certificate
• Malpractice Coverage Documentation
• Delineation of Privilege List Specific to Specialty
• C-Arm Credentials
• Board Certification, if applicable
• Conflict of Interest Statement
• Proof of TB Immunization
• Government Issued Photo ID (Driver’s license)
I look forward to hearing back from you in the very near future. Please feel free to contact me if you have any questions. I can be reached at the following number 970-249-6971.
Dan Soderlind, Administrator
More Information Coming Soon!