Request an Application from the Fairview System Credentialing Office
To request an initial application, add a facility or request additional privileges Click here to complete the application request form. A link to your electronic application packet and privilege form(s) will be emailed directly to the email address you provide on the form.
Initial Credentialing Packet includes:
- MN Uniform Credentialing application
- Privilege form(s)
- Criminal Background Study Disclosure and Authorization Form
- Fairview Authorization and Release
- CME Attestation
- Medicare/Medicaid Attestation
- Immunization Documentation Form
Complete the Immunization Documentation Form included in the packet and fax to the Employee Occupational Health Service number as listed on the form. Please note: your application will not be considered complete and will not be sent to entity for review/approval until proof of immunization compliance is documented by EOHS.
- Application Fee Payment Form
Initial applications require a fee of $200. This form allows the option of payment via credit card or check.
*Application fee for FPA only applications is $150.00
Applicants may review their submitted application and information from publicly available documents at any time during the verification process. If there are discrepancies in the information received during the process, applicants will be allowed an opportunity to provide corrected information.
Contact Information for Initial Appointments Staff
- Initials phone: 612-672-7700 and Press Option 1
- Initials fax: 612-672-4123
- Initials email: SYSTEM-CREDENTIALING-INITIALS@fairview.org
Important information for all applicants:
- All credentialed practitioners are expected to read and be aware of the information contained in the following link:
- Practitioners who hold privileges at a Fairview facility are also responsible to read and be aware of the information contained in the Privileging Principles.
- Proctoring of privileges may be requested if a practitioner does not meet the criteria, such as number of cases performed, as indicated on the privilege form. Proctoring requests must be approved in advance. Information on the process and forms are in the Proctoring Policy .
Initial privilege requests for moderate and/or deep sedation require the completion of a learning packet and test in the Sedation Learning Packet.
Required immunization information:
Immunization compliance is required for all practitioners prior to privileges being reviewed for approval at a Fairview facility. The immunization documentation form must be completed with Initial or Reappointment applications, and faxed to Employee Occupational Health Services (EOHS) as listed on the form.