How to Submit an Application

Request an Application from the MultiCare Health System Credentialing Office

All Applicants: To request an initial application, add a facility or request additional privileges, complete the application request form, using the link below:

Application Request Form

A Washington Practitioners Application packet or Additional membership/privileges application and privilege form(s) will be emailed directly to the email address you provide on the form.

Initial Credentialing Packet includes:

• WPA (Washington Practitioners Application)
• Privilege form(s)
• MultiCare Health System Authorization and Release
• Attestation Questionnaire Form
• Immunization form
• Medicare/TriCare Physician Acknowledgement Statement
• Membership/privileges Hospital Request and Orientation Information
• Provider Handbook and Problem List Attestation
• DEA Attestation (if applicable)
• Application Fee Payment Form

Contact Information for all new and existing credentialed providers:

• MHS Medical Staff Office 253-403-1085
• MHS Medical Staff Office fax: 253-403-4870
• Credentialing email address: [email protected]​

Name, Address, and/or Contact Info Changes and Resignations

If you are currently a practitioner on staff at a MultiCare Health System (MHS) entity (ies), please use the Practitioner Change Form to notify the Credentialing office of any changes to your personal contact information, specifically; legal name changes, home or office address, phone, fax, cell or beeper information that can assist us in ensuring that we have the most current and accurate information in our system to better serve you.

Note: This form can also be used as notification for Resignation from any MHS facility.

• Complete the Practitioner Change Form
• Save as your own document and submit electronically or print and submit a paper copy to:

MultiCare Health System
315 Martin Luther King Jr Way
M/S: 315-C3-CRD
Tacoma, WA 98405
Email: [email protected]
Fax: 253-403-4870