Submit an Application
CAP staff will work closely with all prospective members to help facilitate the application process. To begin the process, please review the Application Checklist and complete all requirements.
Critical Steps for Membership
A few things to remember:
- The membership onboarding process is extremely time-sensitive. If all requirements are fulfilled within a timely manner by the physician, the onboarding process can typically be completed within 90-120 days.
- Failure to complete each stage of requirements in a timely manner may result in processing delays or discontinuation.
- Managed care plan enrollments can be processed ONLY after the onboarding process is completed.
- It is at the individual plan’s discretion to credential/contract a specific provider; processing times vary significantly by plan.
Application Checklist
- CAP Membership Request Form (see attached, to be completed by MD)
- Columbia Sponsoring Department Personal Information Form (see attached, to be completed by MD)
- CAP Credentialing Disclosure and Authorization, Attestation and Release (see attached, to be completed by MD; must include Explanation for any “Yes” answers including Malpractice Case Details for open and settled cases)
- Columbia University Irving Medical Center Confidentiality Agreement (see attached, to be completed by MD)
- CAP Electronic Health Record Attestation Form (see attached, to be completed by MD)
- Two (2) Letters of Recommendation (One letter must be from a current CAP/CD Member)
- Curriculum Vitae (Must include education, training, and last 5 years of work history; must include an explanation for gaps of longer than 6 months; must be formatted in mm/yyyy (month/year) for all items.)
- Current Hospital Privileges Appointment Letter (must include each active affiliation)
- State License Registration Certificate(s) – Include a certificate for each practicing state
- DEA/CDS Certificate(s) – Include a certificate for each practicing state
- Board Certification(s) – Include a certificate for each specialty. If not Boarded: Must submit Internship/Residency/Fellowship training certificates
- Malpractice Liability Coverage Face Sheet
- Infection Control Certificate
- IRS W9 Form – Submit for each Tax ID
- Current Visa or Work Authorization – Non-US Citizens only
- ECFMG Certificate – Required only if the highest level of education institution outside of the US
- Columbia University - Invention Agreement Letter For Distribution