By filling out this online application, I fully understand that any significant omissions, misstatements or
misrepresentations in this application, or during the application process, constitute cause for denial of this application,
or for termination or suspension of my membership and/or clinical privileges at this healthcare organization.
I affirm that the information submitted in or appended to this application is complete, true and current to the best
of my knowledge and belief and is furnished in good faith. In making this application for appointment to this
Healthcare Organization, I acknowledge that I have received the pertinent Bylaws, Rules and Regulations and policies and
Further, I agree to be bound by the terms thereof and to uphold the Bylaws if I am granted membership, employment,
and/or clinical privileges. I further agree to be bound by the terms of the Bylaws without regard to whether or not I
am granted membership and/or clinical privileges in all matters relating to the consideration of my application for
appointment to this Healthcare Organization. I further agree to comply with all applicable federal and State laws,
as well as government regulations, in addition to specific department and/or service rules and regulations.
I authorize this Healthcare Organization and its/their representatives to consult with representatives of other healthcare
organizations with which I have been affiliated, including licensing authorities, businesses, and others who may have information
bearing on my competence, character, and ethical qualifications. I authorize and direct persons so consulted to provide such
information to this Healthcare Organization. I understand that letters of recommendation concerning me are to be written and
maintained in confidence, and I waive any rights I might have to access to such letters.
By logging in I acknowledge that I have read and agree to be bound by all the above information.
If you are having technical issues with MD-App, including viewing or printing documents, logging in to the website, or submitting your application, please contact ASM Support:
If directed by a support representative, click here to begin a GoToAssist® session
Viewing and/or printing the application or application packet requires Adobe Reader version 6.0 or greater.
If you do not have Adobe Reader or an equivalent PDF viewer,
click here to download the latest version for free from Adobe.
For issues related to the application content or the application requirements, please contact the medical staff office.