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State of West Virginia Recredentialing Form:  Misrepresentation of any statements and information provided by you in support of this application shall be considered fraudulent and may result in denial or revocation of appointment.  (If more space is needed, please supply the information on a separate sheet and attach.)

Staff Status

# Admits/Month

Percent of time spent at facility

Restricted?

Dates of Affiliation (Mo/Yr)

Yes No

If yes, explain:  

From: To:

Reason for leaving, if applicable

9.Additional Affiliations:

(Photocopy this page for additional affiliations)

Name of Affiliation/Hospital/Healthcare Entity

Type of Affiliation (e.g., Hospital, Nursing Home, etc.)

Street Address

City

State

Zip

Telephone Number

Fax Number

() -

() -

Department/Service

Department Chair’s Name

Staff Status

# Admits/Month

Percent of time spent at facility

Restricted?

Dates of Affiliation (Mo/Yr)

Yes No

If yes, explain:  

From: To:

Reason for leaving, if applicable

Name of Affiliation/Hospital/Healthcare Entity

Type of Affiliation (e.g., Hospital, Nursing Home, etc.)

Street Address

City

State

Zip

Telephone Number

Fax Number

() -

() -

Department/Service

Department Chair’s Name

Staff Status

# Admits/Month

Percent of time spent at facility

Restricted?

Dates of Affiliation (Mo/Yr)

Yes No

If yes, explain:  

From: To:

Reason for leaving, if applicable

Name of Affiliation/Hospital/Healthcare Entity

Type of Affiliation (e.g., Hospital, Nursing Home, etc.)

Street Address

City

State

Zip

12/02; 3/03; 11/03; 1/04; 5/04; 10/04     **Confidential and Privileged Peer Review Pursuant to WV Code 30-3C-1 et.seq** Page 10

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