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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
  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.

Learn more about the reappointment process.