Phase I Forms for Clinical Faculty New Hires

Clinical Staff Membership - Initial Appointment Credentialing Documents

Congratulations and Welcome to the UVA Health System!

Within 5 days after signing your offer packet, please complete the following:

1.  Complete, print (in order to physically sign), and sign the following forms (requires Adobe Acrobat Reader):
a.  Clinical Staff Membership Application  

b.  Electronic Access Agreement 

c.  Background Check Consent Form  


2.  Please return the completed and signed forms to the Clinical Staff Office:

If returning the forms via email is not feasible, you may choose one of the following alternatives:

  • Fax all documents to 434.244.7548
  • Mail all documents to:
    Clinical Staff Office
    University of Virginia Medical Center
    1215 Lee Street
    McKim Hall, Room 1098
    Charlottesville, VA 22908-0547
Incomplete forms and/or materials submitted beyond five days after the date of signing offer packets may impact timeliness of the credentialing and privileging processes.   This includes the need to submit a photo with the Clinical Staff Membership Application - see page one.


Contact us if you have any questions via:

We will be in touch with you once the forms are received regarding Phase II (the final steps) of the hiring process.

Thank you!

We look forward to the successful completion of your hiring process!