APPLICATION
Application for Medical Staff Appointment and Clinical Privileges for The Surgery Center of Fairbanks
Please print all information clearly. If the existing space is insufficient, please attach additional sheets and reference the question being answered.
Personal Data
Malpractice Insurance
Education
Internship
Residency
Other Residencies
Fellowships
Teaching Appointment
Board Certification
Licenses and Other Certifications
Licenses and Other Certifications
Hospital Affiliations
References
Please submit copies of your CME certificates for the past 2 years. Must be at least 50 credits for the past two years for Medical and 32 credits for the past two years for Dental.
Policies and Procedure
Applicant’s Consent and Release
Attestations and Disclosures
for The Surgery Center of Fairbanks, LLC