Medical Staff Application

APPLYING FOR PRIVILEGES

To apply for privileges at CalvertHealth Medical Center, please complete the following steps:

1. Download and complete the CalvertHealth Pre-Application form and mail to CalvertHealth Medical Center, Medical Staff Services, 100 Hospital Road, Prince Frederick, MD 20678 along with our $100 pre-application fee. The medical staff office will notify you when this application has been approved. Once approved, you may apply for initial credentialing which details the following steps:
   
   
   • Download and complete the Maryland State Credentials form.
   • Download and complete the CalvertHealth Supplemental Application form.
   • Fill out the Delineation of Privileges form request. The appropriate form for your specialty will be e-mailed to you within two business days.
   • Once completed, mail all three forms to the mailing address below.

CalvertHealth
ATTN: Medical Staff Services
100 Hospital Road
Prince Frederick, MD 20678

If you have any questions, please contact our team by emailing linda.tierney@calverthealthmed.org or 410.535.8242

Other Required Forms

• Cover Letter
• Malpractice Claims History Reporting Form & Authorization to Release
• Contact Information Form
• Criminal Records and Background Release - Authorization and Disclosure
• Rules & Regulations | Medical Staff Bylaws 2020
• Summary of Your Rights Under FCRA (english)
• Summary of Your Rights Under FCRA (spanish)

Special Privilege Requests

• Procedure Sedation Packet & Test
• Fluoroscopy Packet & Test