All Fields Required

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Membership

* Participating with Kettering Health Physician Partners requires a completed CAQH application on file.

Kettering Health Physician Partners (Membership w/KH Facility Privileges)
Kettering Health Physician Partners (Membership Only)
N/A

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Medical Centers / Hospitals

KH Fort Hamilton (KHHM)
KH Miamisburg (KHMB)

KH Dayton-Washington TWP (KHDO)
KH Troy (KHTR)

KH Greene Memorial (KHGM)
Soin

KH Main Campus (KHMC)
N/A

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Utilization Disclosure (reason for privilege request)

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Personal Info - (Name as it appears on OHIO State License)

First Name

Middle Name

Last Name

Maiden Name (Optional)

Date of Birth

Degree

Specialty

Group Name

NPI  (if known)

Office Name

Office Address

Office City

Office State
AK AL AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY

Office Zip

Office Phone

Office Fax

Preferred Email  (REQUIRED to complete app)

SSN (Last 4)

Do you have an OHIO Medical License?
Yes
No

Have you ever had a Kettering Health badge?
Yes
No

Are You Requesting "Clinical Privileges"?
Yes
No

Are you currently Board Certified?
Yes
No

Board Eligible?
Yes
No

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Submit