"*" indicates required fields Credentialing Status*Initial RVU Clinical Faculty Credentialing or Re-Credentialing for Existing RVU Clinical Faculty Initial Credentialing Recredentialing Name* Select if applicable.Dr.Mr.Mrs.Ms. Title First name Middle name (or initial) Last name Date of Birth* MM slash DD slash YYYY Gender*Please select.MaleFemaleOther/Prefer not to discloseCell phone:Fax number:Email address:* Office phone:*Provider type:*Please select.PhysicianPhysician AssistantAdvanced Practice NurseMental Health ProviderOther Allied Health ProfessionalPlease list your supervising physician:*To see information on RVU's Title IX policy, please click here:*Title IX I attest to having read and understand RVU’s Title IX Policy and Conflicts of Interest & Student Confidentiality in the Clinical Setting Policy. PRACTICEPractice name:*Practice address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Practice type:* Outpatient Inpatient Surgical center Long term care facility/Rehab Emergency/Urgent care Teaching residents at practice site Other Primary Speciality*Allergy & ImmunologyAnesthesiologyCardiovascular SurgeryColon & Rectal SurgeryDermatologyEmergency MedicineFamily MedicineGeneral SurgeryInternal MedicineNeurological SurgeryNeurologyOBGYNOphthalmologyOrthopedic SurgeryOtolaryngologyPathologyPediatricsPhysical Medicine and RehabilitationPlastic SurgeryPsychiatryRadiation OncologyRadiologyUrologyVascular/Thoracic SurgeryOtherSubspecialtyIf other, please explain:*List the hospital(s) used in your clinical practice. (Please type "N/A" if none.)Office ContactOffice Contact Email: Please list here any changes to your practice, from your initial certification, that you would like to note for the Clinical Education team.Students accepted for rotation:* Third-year medical students Fourth-year medical students Physician assistant students EDUCATIONAL INFORMATIONProfessional School:*Grad year:*Credentials* MD DO APRN PA-C PhD PsyD LCPC DPM DDS Other Other*Residency (if applicable):Grad year:LICENSURELicense number:*Licensure type:*e.g. Medical, PA, ANPThis field is hidden when viewing the formLicense UploadMax. file size: 512 MB.State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLicensure expiration date:* MM slash DD slash YYYY CERTIFICATION:Are you board certified?* Board certified Board eligible Not certified Certification type (ABFM, FACOFP, NCCPA, etc.):*Certification number:Date first certified:* MM slash DD slash YYYY Is this a lifetime certification?* Yes No Certification expiration date:* MM slash DD slash YYYY Please attach your certification:(.doc, .docx, or .pdf) Drop files here or Select files Accepted file types: doc, docx, pdf, Max. file size: 10 MB. Please explain how you are board eligible:*Please explain your reasoning for application without board certification:*Would you like an adjunct clinical faculty rank appointment from Rocky Vista University?* Yes No Would you like online access to the Frank Ritchel Ames Memorial Library at Rocky Vista University? Yes No Please attach your CV:*(.doc, .docx, .pdf) Drop files here or Select files Accepted file types: doc, docx, pdf, Max. file size: 10 MB. Please attach your certificate of insurance (Malpractice COI):(.doc, .docx, .pdf) Drop files here or Select files Accepted file types: doc, docx, pdf, Max. file size: 10 MB. COI expiration date: MM slash DD slash YYYY Would you like online access to the Frank Ritchel Ames Memorial Library at Rocky Vista University?* Yes No Additional Comments or Questions:Name of the RVU contact with whom you are working:*Please select.Amie KoenigAmy HumphriesAmy MaupinAngela HallAshlee BishopChristy Hardt (PA)Dr. Dan ChappellDr. George IssaDr. Joel DickermanDr. John NicholsDr. Johnny ChengDr. Josh ToldDr. Mark LeeDr. Megan HaldyDr. Ryan SpilmanDr. Tom ToldJaime CovingtonJennifer WatsonKatie ConverLaura RubinLia NullMichelle KochMorgan BaileyNicole BishopKristen Hunter (PA)Kristin Kelley-GomezSarah NordgranStephen BoucherVanessa LundOtherPlease specify:*If this form is being submitted on behalf of the preceptor, who is submitting this form?*Note: Students may not enter submission on behalf of the preceptor.*Your e-mail address, if you are submitting on behalf of the preceptor: If you have any questions, please contact Preceptor Staff Services in the Clinical Education Department at shampton@rvu.edu.This field is hidden when viewing the formRotation name: Internal Medicine Core Family Medicine Core Psych Core Pediatrics Core Surgery Core OB/GYN Core Elective This field is hidden when viewing the formPlease specify the elective: