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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.)

9.Hospital/Health Care Entity Affiliations:

Check here if entire section is not applicable to applicant.

List ALL health care facilities at which you currently have privileges or have had privileges SINCE DATE OF LAST CREDENTIALING.  Explain gaps greater than three (3) months during the period in Section 11.

Name of Current Primary Hospital Affiliation

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

Telephone Number

Fax Number

() -

() -

Department/Service

Department Chair’s Name

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 9

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