Physician Dentist Support Staff Request

DO NOT USE - go to Medical Staff Services Website for most recent Provider Information Form (PIF).

In keeping with the requirements set forth by The Joint Commission, regarding Physician/Dentist Support Staff members our HR Standard (HR.01.02.05, EP7) specifically requires “that prior to the provision of care, the qualifications and competence of a non-employee brought into the hospital by a licensed independent practitioner to provide care, treatment, or services are assessed by the hospital and determined to be commensurate with the qualifications and competence required if the individual were to be employed by the hospital to perform the same or similar services.” Atrium Health has developed a process to accomplish this assessment.

Please complete the New Provider Information Form and send it to MSSproviderREQ@AtriumHealth.org. Upon receipt of this form you will be contacted by the Medical Staff Office with further instructions