Fairview System Credentialing Office

How To Submit An Application to the Fairview System Credentialing Office

PLEASE SELECT ONE OF THE THREE OPTIONS BELOW:

OPTION 1:  “I am currently a practitioner on staff at a Fairview entity and would like to apply to another Fairview entity.”  Please contact Shalisa Moore in the Fairview System Credentialing Office by e-mail smoore9@fairview.org or by phone at 651-917-1443 to request an Update Application.

OPTION 2:  “I am currently a practitioner on staff at a Fairview entity(ies) and would like to request additional privileges for that entitiy(ies)."  Follow the instructions listed below.  If you have any questions, contact the Fairview System Credentialing Office at 612-672-7700, option 1.

• Print and complete the Additional Privileges Request Packet.
• Select, print and complete the appropriate privilege form(s) listed below.
• Mail the Additional Privileges Request Form and privilege forms(s) to:
  Fairview System Credentialing Office
  2344 Energy Park Dr Ste 127

       St. Paul, MN 55108
             or  
       Email to fsco@fairview.org
             or
        Fax: 612- 672-4123

OPTION 3:  New Fairview applicants:

• Electronic Submission:  You may submit your application electronically to Fairview Health Services or Behavioral Healthcare Providers via the Minnesota Credentialing Collaborative (MCC) ApplySmart web-based credentialing application at www.mncred.org to join or if you already have an account login at www.credentialsmart.net/mcc. 
  
• Paper Submission: Fairview and Behavioral Healthcare Providers will also continue to accept applications via paper applications.  Please follow the Print and Submit instructions below:

Print out all of the following documents:
     1.  Initial Credentialing Information Packet
     2.  Initial Credentialing Application Form
     3.  Privilege Forms
          Note:  Privilege forms are not required if only applying to Fairview Physician Associates (FPA) and/or Behavioral Healthcare Providers (BHP)

Submit the completed credentialing application and privilege form(s) with all required supporting documentation to FSCO@fairview.org or mail to:

Fairview System Credentialing Office
Initial Applications
2344 Energy Park Dr Ste 127
St. Paul, MN 55108
 

1.  Initial Credentialing Information Packet

• Physicians, Dentists, Podiatrists
• All Other Health Care Practitioners  

Included in this packet:

• Initial Application Cover Letter
• Credentialing Checklist
  The Credentialing Application Checklist is a valuable tool to assist in completing the credentialing application and to ensure you are submitting a complete application. Incomplete applications are returned to the practitioner or clinic and creates a substantial delay in the practitioner’s credentialing process.
• Criminal Background Study Disclosure and Authorization Form
  Minnesota state law requires all health care practitioners complete a Criminal Background Study prior to participating in patient care activities. This form will authorize the Fairview System Credentialing Office to electronically submit a background study request to the Minnesota Department of Human Services. Our office cannot complete the credentialing verification process until the Criminal Background Study form is submitted and a response is received.
• Fairview Authorization and Release
  Fairview has its own Authorization and Release form that must be completed in place of the Authorization and Release form included in the MN Uniform Credentialing Application. As part of its service to practitioners, Fairview System Credentialing Office provides delegated credentialing services to health plans and provider networks. When you apply to a Fairview entity, you accept certain conditions regarding immunities and authorizations to obtain or release information, including the release of information to these health plans and provider networks.
• Immunization Documentation Form
  Complete theImmunization Documentation Form included in the packet and fax to the Employee Occupational Health Service number as listed on the form. 
• Initial Application Flowchart
  This flow chart outlines the initial application process at Fairview.  In addition, contact names and phone numbers are listed if you have questions regarding your application.  
• Application Fee Payment Form
  Initial applications require a fee of $200.  This form allows the option of payment via credit card or check. 

2.  Initial Credentialing Application Form

• Print and complete the paper copy of the Minnesota Uniform Credentialing Application- Initial.

3.  Privilege Forms, click here.

 Contact Information for Initial Appointments Staff

• Practitioners with Last Names Starting with A-L:   612-672-7594
• Practitioners with Last Names Starting with M-Z:   612-672-7591
• Update Applications and Additional Privileges:  612-672-4276
• Behavioral Healthcare Provider (BHP) Applications:  612-672-7725 or 612-672-4352
• Initials Office fax:  612-672-4123