Physician Information

Medical Staff Policies
Medical Staff Bylaws
Medical Staff Rules & Regulations

DCMH Physician Application and Re-Application Forms
*Please print, complete and return the forms listed below to DCMH Administration, 720 N. Lincoln Street, Greensburg, Indiana 47240.
Attestation Notice Acknowledgement Medicare/Champus Form
Release of Liability Practitioner’s Statement Form
Release of Authorization and Fair Credit Reporting Act
Conflict of Interest Disclosure Statement Form
Confidentiality Statement Non-Employee with Access to Protected Health Information & HIPAA Test Form
LIP Health Records Verification Form
Medical Staff Rules & Regulations
Medical Staff Code of Conduct (Read Only)
Medical Staff Bylaws (Read Only)
Medical Staff Application & Reapplication Fee Form

DCMH Physician Application and Re-Application Forms
*Print, sign and return all applicable lists to DCMH Administration along with forms listed above.
Allergy Immunology Privileges
Anesthesiology Privileges
Cardiology Privileges
Clinical Nurse Specialist Privileges
CRNA Privileges
Dentistry Privileges
Dermatology Privileges
Emergency Med Privileges
Endocrinology Privileges
ENT_Otolaryngology Privileges
Family Medicine Privileges
Gastroenterology Privileges
General Surgery Privileges
Hemotology Oncology Privileges
Internal Medicine Privileges
Mental Health Counselor Privileges
Nephrology Privileges
Neurology Privileges
Nurse Practitioner Privileges
OB_GYN Privileges
Ophthalmology Privileges
Optometry Privileges
Orthopedic Surgery Privileges
Pathology Privileges
Pediatric Privileges
Physical Med & Rehab Privileges
Physician Assistant Privileges
Podiatric Surgery Privileges_admitting privileges
Psychiatry Privileges
Pulmonary Medicine
Radiology Privileges
Telemedicine Privileges
Urology Privileges
Vascular Surgery Privileges
Wound Care