Medical Staff Application
Thank you for your interest in Floyd Healthcare System. To become an active member of the medical staff at Floyd Medical Center, Polk Medical Center or Floyd Primary Care Network, complete the pre-application form and return it to the Floyd Medical Staff Office by fax to 706.509.6901 or by email to firstname.lastname@example.org.
Once your pre-application has been received, a member of our Medical Staff Office will email a link to complete the online Medical Staff Application. To appoint a delegate to enter data and submit documents through the Floyd application portal, include the delegate authorization form along with the preregistration form.
All applicants are required to meet the prerequisites for receiving the application for appointment. By completing the pre-application form, you certify that you meet the minimum requirements outlined below.
Pre-application Minimum Requirements
All Providers (Physician, Dentist, Oral Surgeon, Podiatrist and Allied Health)
- Current unrestricted license to practice medicine in Georgia and no record of past adverse licensure action.
- Current Federal Narcotics License (CDS, DEA) and no record of past adverse licensure action.
- Current malpractice insurance with a minimum of $1,000,000/$1,000,000.
- Proof of Board Certification or letter indicating registration to take the examination in your area of practice by appropriate specialty board (AMBS or AOA). (Board certification is required no later than five years after the date of completing residency training or two years after first being granted clinical privileges, whichever comes later.) Allied Health providers are also required to be board certified in their specialty.
- No record of conviction of Medicare, Medicaid or insurance fraud and abuse, payment of civil money penalties for same, or exclusion from such programs.
- No record of denial, revocation or termination of appointment or clinical privileges by any hospital for reasons related to professional competence or conduct.
- No record of conviction of, or entered a plea of guilty or no contest to, any felony, or to any misdemeanor related to controlled substances, illegal drugs, third-party reimbursement or violence.
Physician, Dentist, Oral Surgeon, Podiatrist Only
- Residence and office located sufficiently close to the medical center to fulfill medical staff responsibilities and to provide timely and continuous care for patients (as outlined in the medical staff bylaws).
- Satisfactory completion of an ACGME or AOA approved postgraduate residency training program (or a residency training program approved by a comparable Canadian accrediting body) in the specialty in which you will seek clinical privileges, or, graduate of an approved dental school, or, graduate of a school of podiatric medicine accredited by the Council on Podiatric Medical Education of the American Podiatric Medical Association and have completed at least 12 months of formal post-graduate training in an institution approved by the Council on Podiatric Medical Education of the American Podiatric Medical Association.
- Participation in emergency call rotation and to treat all patients referred to you regardless of ability to pay.
- Backup coverage for admitted patients when you are unavailable.
Completed forms and questions can be directed to the Floyd Medical Staff Office at 706.509.6915 (phone), 706.509.6901 (fax) or email@example.com.