Request for Application

Pre-Application Questionnaire

REMINDER: Please email the following to credentialing@ghcares.org after submitting this questionnaire:

a. Current License(s) to practice medicine in any state

b. Current DEA certificate

c. Current Professional Liability Insurance face sheet

d. ECFMG certificate (if foreign medical graduate)

e. Current Board Certification or eligibility status

f. Current Curriculum Vitae