The below forms and education requirements are included in the online eCredentialing application.

Click each form to review the form. Please do not print and attest the forms. Applicants are required to attest the forms within the eCredentialing application.

• • Release of Information Form | Credentialing/Criminal Background Check (#2129)
• • Standards of Conduct Acknowledgement
• • Blue Cross Blue Shield Hospital Coverage Letter
• • Clinical Integration Physician Compact
• • Hospital Admitting Form
• • Fraud, Waste, and Abuse Education

Questions?

Please reach out to MHMD’s Credentialing Department by email, phone or fax.
Email | enterprise.credentialing@memorialhermann.org
Phone number | 713.338.6464, select option 3, and then select option 3
Fax number | 713.338.6964