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Do not apply if you have been credentialed for hospital privileges and/or payor enrollment. 

In the case of an emergency, any individual who has been granted clinical privileges is permitted to do everything possible within the scope of his/her license, to save a patient’s life or to save a patient from serious harm, regardless of staff status or privileges granted. The purpose of this form is to ensure that the individuals, who are not Appointees to the Medical Staff, and who are requesting Disaster Privileges are qualified and licensed to provide care.

To confirm ID, an MSS teammate will confirm the identity of the provider via government issued ID via facetime or Skype. If there are any concerns identified by the MSS teammate following the verification process, the provider will be notified immediately regarding their eligibility. Otherwise, temporary disaster privileges will be granted.

Please answer each of the following questions. If the answer to any question is yes, please provide full explanation.
I certify that I am trained and experienced in the privileges requested, hold a current unrestricted license, registration, or certification to practice medicine and a current DEA, and that the information above is true and correct. I understand that in making this request to volunteer my medical services during this disaster, I am bound by the applicable Bylaws, rules and policies of the Hospital and Medical Staff. I further acknowledge that when the disaster no longer exists, these Disaster Privileges will be immediately terminated, and I must request privileges through the normal Medical Staff process if I wish to continue treating patients at this facility.
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