Request for Application

Before an application can be released, you must first complete a Request for Application form. Please complete the form for initial appointment and for adding a new facility.

Completion of the form will allow you to apply for hospital credentialing, MHMD membership or the Health Plan.

1. Download and print the Request for Application form for Memorial Hermann hospitals, affiliate hospitals and surgery centers, MHMD membership or to be enrolled with the Memorial Hermann Health Plan.
2. Upload the completed and signed form to your device and email it to enterprise.credentialing@memorialhermann.org.
3. Requests are processed in 1-2 business days. After your request has been processed you will receive an initial pre-screening call from a member of Memorial Hermann’s Network Management team.
4. After the pre-screening qualifications are met, you will receive your Memorial Hermann eCredentialing Portal & Application username and password via email.

Reappointment

Medical Staff Credentialing appointments are aligned to meet the single reappointment period. Prior to your reappointment deadline, you will receive two emails with your login username and password information.

In order to ensure timely processing, please complete your reappointment application promptly. If you are interested in requesting additional hospital affiliations, request an application.