Sutter Independent Physicians
Primary Care Physicians
Member Interest Form

In addition to completing this form, please email a statement of interest along with a current CV to Danielle Conner at danielle.conner@sutterhealth.org or fax to 916-503-3751.

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* 1. PHYSICIAN DETAILS

Full Name & Degree (MD, DO)

CA License Number

Individual NPI

DOB

Primary Specialty

Preferred Email

Cell Phone

Preferred Pronouns: her/she, him/he, they/them

Start Date/Opening Date:

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* 2. Patient age restrictions?

Yes (please list age range accepted)

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* 3. MEMBERSHIP TYPE
Will physician be available for patient care at least 5 half days per week?

Yes

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* 4. Type of membership request:

Member (rostered and accepting a patient panel)

Call coverage (part-time/per diem, not rostered and not accepting a patient panel)

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* 5. Are you currently Board Certified?

Yes, please list specialty(s):

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* 6. CLINIC OFFICE DETAILS
Please ensure this information is correct, and clinic address includes suite number (if applicable). This information should appear as you would like listed on public directories. *If you have more than 3 clinic locations, please indicate this on your Letter of Interest.

Practice DBA (doing business as)

Primary Clinic Office Address:

Primary Office Phone:

Primary Office Fax:

2nd Clinic Office Address:

2nd Office Phone:

2nd Office Fax:

3rd Clinic Office Address:

3rd Office Phone:

3rd Office Fax:

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* 7. OFFICE CONTACT DETAILS

Office Manager Name:

Office Manager Email:

Office Manager Phone:

Credentialing Coordinator Name* (Person helping you with credentialing application):

Email Address

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* 8. DIRECT PHYSICIAN/OFFICE PHONE NUMBER
Our Laboratory Department and Hospitalist Program request a direct phone number be on file for urgent matters that might arise regarding your patients. Please list your preferred direct phone number for these situations.

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* 9. HOSPITAL PRIVILEGES
Do you currently have, or are you in the process of obtaining, Sutter hospital privileges?

Yes

None of the above

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* 10. If yes, at which Sutter Hospitals?

Sutter Auburn

Sutter Davis

Sutter Roseville

Sutter Sacramento

N/A

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* 11. Do you have any Advanced Clinicians (Nurse Practitioners, Physician Assistants) practicing under your supervision? Licensed clinicians in your practice will need to be credentialed prior to treating Sutter patients.

Yes, please list their names.

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* 12. VACCINE ATTESTATION
Does clinician support the CDC recommended vaccination:

	Yes	No
For themselves?	For themselves? Yes	For themselves? No
For their patients?	For their patients? Yes	For their patients? No

Vaccine comments (optional). *You may be asked to provide more details regarding vaccinations.

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* 13. Does your office use an Electronic Medical Record (EMR) for medical charting (answer "NO" if EMR is only for billing/scheduling purposes)?

If Yes, my EMR/EHR system/vendor is:

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* 14. Would you like more information about Sutter Community Connect (SCC), Sutter's EPIC EMR system?

Yes, I would like more information. Please have someone contact me.

No, I am not interested.

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* 15. PLEASE NOTE: A statement of interest and CV is required; send to Danielle Conner at Danielle.Conner@sutterhealth.org. This submission of interest is NOT authorization to render medical care to contracted health plan members. Please ensure physician and office contact emails listed on this form are accurate.

Agree

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* 1. PHYSICIAN DETAILS

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* 2. Patient age restrictions?

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* 3. MEMBERSHIP TYPEWill physician be available for patient care at least 5 half days per week?

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* 4. Type of membership request:

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* 5. Are you currently Board Certified?

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* 6. CLINIC OFFICE DETAILSPlease ensure this information is correct, and clinic address includes suite number (if applicable). This information should appear as you would like listed on public directories. *If you have more than 3 clinic locations, please indicate this on your Letter of Interest.

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* 7. OFFICE CONTACT DETAILS

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* 8. DIRECT PHYSICIAN/OFFICE PHONE NUMBEROur Laboratory Department and Hospitalist Program request a direct phone number be on file for urgent matters that might arise regarding your patients. Please list your preferred direct phone number for these situations.

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* 9. HOSPITAL PRIVILEGESDo you currently have, or are you in the process of obtaining, Sutter hospital privileges?

Question Title

* 10. If yes, at which Sutter Hospitals?

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* 11. Do you have any Advanced Clinicians (Nurse Practitioners, Physician Assistants) practicing under your supervision? Licensed clinicians in your practice will need to be credentialed prior to treating Sutter patients.

Question Title

* 12. VACCINE ATTESTATIONDoes clinician support the CDC recommended vaccination:

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* 13. Does your office use an Electronic Medical Record (EMR) for medical charting (answer "NO" if EMR is only for billing/scheduling purposes)?

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* 14. Would you like more information about Sutter Community Connect (SCC), Sutter's EPIC EMR system?

Question Title

* 3. MEMBERSHIP TYPE
Will physician be available for patient care at least 5 half days per week?

* 6. CLINIC OFFICE DETAILS
Please ensure this information is correct, and clinic address includes suite number (if applicable). This information should appear as you would like listed on public directories. *If you have more than 3 clinic locations, please indicate this on your Letter of Interest.

* 8. DIRECT PHYSICIAN/OFFICE PHONE NUMBER
Our Laboratory Department and Hospitalist Program request a direct phone number be on file for urgent matters that might arise regarding your patients. Please list your preferred direct phone number for these situations.

* 9. HOSPITAL PRIVILEGES
Do you currently have, or are you in the process of obtaining, Sutter hospital privileges?

* 12. VACCINE ATTESTATION
Does clinician support the CDC recommended vaccination: