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Applying For Medical Staff Membership

To apply for initial Medical Staff membership and privileges at Mercy Medical Center, please submit your request in writing along with a current copy of your C.V. (in month and year format) to the Medical Staff Affairs office. Your request can be faxed or mailed as follows:

Medical Staff Affairs
Mercy Medical Center
1000 N. Village Avenue
PO Box 9024
Rockville Centre, NY 11571-9024
Fax: (516) 705-2539

Once your request is received, the documents will be reviewed by the respective Department Director. You will then be contacted to set up an in-person interview with the Department Director.

Following your interview, an initial application will be mailed to you for completion.

The Initial Application Process

The completed application should be returned to the Medical Staff Affairs Office along with an Initial Application Fee of $150.00.

During the processing of the application, you will be contacted via mail or e-mail and advised of any missing or incomplete documentation.

When the initial application process is complete, the Medical Staff Affairs office will contact you to request your presence at the next scheduled meeting of the Credentials Committee.

Following the approval of your application at the Credentials Committee, the file is then presented to the Executive Committee of the Medical Staff, the Performance Improvement Committee, and the Executive Board of Trustees.

Once approved at the Board of Trustees, your privileges will be granted.

A Welcome letter and a copy of your approved Delineation of Privileges will be mailed to you.

In order to speed the initial application process, please be sure to include the following documents along with your completed initial application:

  • Initial Application fee of $150.00
  • Completed Initial Application Packet
  • Health Assessment Form
  • Copy of Current PPD or Chest X-Ray Report
  • Copy of Titers
  • Completed Delineation of Privileges and Procedure Log
  • Clear Photo ID (Driver's License or Passport)
  • Copy of NY State License
  • Copy of Signed NY State Registration
  • Copy of DEA Certificate
  • Copy of Infection Control Certificate
  • ACLS / BLS Certificate (Required for all PA's and Physicians in Critical Care)
  • Medical School Diploma (If PA - PA Diploma, If NP - Nursing Diploma)
  • Internship Training Certificate
  • Residency Training Certificate(s)
  • Fellowship Training Certificate(s)
  • ECFMG Certificate (If applicable)
  • NCCPA Certificate (for PAs)
  • ANCC Certificate (For NPs)
  • Copy of Board Certification
  • CME Certificates
  • Malpractice Insurance Certificate (Naming Mercy Medical Center as the Certificate Holder)
  • Names, Addresses, Phone and Fax numbers of three Peers

Guidelines for Peer Evaluations:

Peer references must be from persons with the same professional license as the applicant, practicing in the same field or specialty, at least one of whom is or has been a supervisor of the applicant - e.g. Clinical Chairperson, Chief of Service, Division Director of a service or division in another institution or facility in which the applicant is or has been affiliated, or the applicant's residency training director the residency program relevant to the clinical department in which the applicant seeks clinical privileges. The Peer completing the form must be able to provide adequate references pertaining to the applicant's professional competence, ethics and character.