For help with this form , or if you have not received a reply within 24 hours of submitting your request, please contact the Piedmont Healthcare Central Verification Office at 770-801-2730 or PHC-CVO@piedmont.org.
If moving residence, anticipated location of local address
Please select all the facilities to which you would like to apply and your desired medical staff status for each facility you select.*
I UNDERSTAND AND AGREE THAT THIS FORM IS NOT AN APPLICATION AND DOES NOT CONFER ANY RIGHTS, INTEREST OR PRIVILEGES TO ME, BUT IS MERELY A COMMUNICATION TOOL TO ASSIST HOSPITAL IN ASSESSING MY QUALIFICATIONS FOR RECEIPT OF A MEDICAL STAFF APPLICATION.
I hereby consent to the exchange of information and documents relating to my credentials and qualifications between Piedmont Healthcare and any licensing authorities, businesses, and/or individuals acting as their agents, for the purpose of evaluating this preliminary inquiry regarding my eligibility to provide medical services to this facility. I further consent to the release, disclosure, inspection, and reproduction of any such information and documents as becomes necessary during the evaluation process with regard to my inquiry.
I hereby affirm that the information I have submitted to Piedmont Healthcare, and any addenda thereto (including my curriculum vitae), are true, current, correct, and complete to the best of my knowledge and belief, and are furnished in good faith. I understand that material omissions or misrepresentations may result in my application being administratively withdrawn or denial of my application.
I acknowledge that I have read the foregoing and that I have complied with and hereby consent to the terms, conditions, and requirements stated herein. I therefore agree to the release, disclosure, inspection and reproduction of information and documents received by Piedmont Healthcare in conjunction with my inquiry, and confirm that any/all information provided by me is accurate and complete to the best of my knowledge and belief.
I do not agree to the foregoing release and acknowledgment, and understand that by checking this box I will not be considered as a candidate to provide medical services to Piedmont Healthcare.
* For security purposes, please enter the code you see below: