Requests to add NEW CLINICAL PRIVILEGE/PRACTICE SITES for existing clinical providers* are to be completed and submitted only by a clinical unit’s designated HR Representative, Division Administrator, Chair, Dean or their designated delegates.
NOTE:
The information requested below is for 1004.24 FBOG HEIC and self-insurance privileged and confidential underwriting purposes only and does not meet participants’ independent credentialing or other required hiring background, screening, and/or on boarding processes.
* Providers (employees or volunteers) who deliver professional healthcare services on behalf of the university or SIP protected hospital/entity.
Please complete the below and allow up to seven business days for processing by your SIP Insurance Services Office (ISO). This form allows for the addition of up to three sites per provider. If additional sites are needed, a new form will need to be completed and submitted. Once processed by ISO, the new privilege/practice site(s) will appear in your portal detail.