Medical Staff Application Process

Thank you for your interest in applying for the Mountain States Health Alliance Medical Staff.

Please note: when requesting privileges for more than one hospital you need only fill out one application.  However, you will need to complete a privilege form specific to each facility.

The Medical Staff Application process is divided into ten sections:

1. Medical Staff Application
2. Application Fee
3. Privilege Forms
4. Delivery of the Application to Medical Staff Services
5. Review and verification of the application by Medical Staff Services
6. Review by the Department Chair
7. Review by the Credentials Committee
8. Review by the Medical Executive Committee and County Board 
9. Completion of the MSHA Physician Orientation class
10. Review and approval by the MSHA board

Before you return the application packet, please review all of your materials thoroughly for accuracy, completeness, signatures and dates.  Please note that we cannot begin processing your application until the items listed below have been received, including all check boxes, blanks, and signatures completed. 

• All professional licenses in Tennessee or Virginia and other states
• DEA certificate for each state where you have an active medical license
• Curriculum Vitae or Resume covering your work history (from medical school to present) with month and year in chronological order
• Malpractice Insurance Certificate with the names and contact information of any other insurance carriers during the last five years.
• All supporting forms - Expectations Form, Consent to Release, Information Form, SVMIC release form, Pharmacy Signature Sheet, and Physician Acknowledgment Form
• Application Fee of $200 (If applying for multiple facilities, there is a $25 fee for each additional facility)
• Photo - recent professional photo (you can email an electronic copy to medicalstaffservices@msha.com) and a copy of drivers license or passport)

Processing Time:  

Our standard processing time is 90 - 120 days following receipt of a completed application.

Please note:

The Medical Staff application is available in an Adobe Reader (PDF) format.  If you do not have Adobe Reader, you can download a free copy at http://www.adobe.com/downloads/

You can complete the application in Adobe, then print it and mail it to our office:

MSHA Medical Staff Services
400 North State of Franklin Road
Johnson City, TN 37604
Attn: Diane Stine

To begin the application process, please click here