Anticipated Start Date

Facilities Applying To
Ballard Rehabilitation HospitalGateway Rehabilitation HospitalKentfield HospitalKentfield Hospital San FranciscoRehabilitation and Critical Care Hospital of the Black HillsSan Joaquin Valley Rehabilitation HospitalSouthern Indiana Rehabilitation HospitalSouthern Kentucky Rehabilitation HospitalVibra Hospital of BoiseVibra Hospital of CharlestonVibra Hospital of Clear LakeVibra Hospital of DenverVibra Hospital of FargoVibra Hospital of HoustonVibra Hospital of Northern CaliforniaVibra Hospital of RichardsonVibra Hospital of SacramentoVibra Hospital of Southeastern MassachusettsVibra Hospital of Southeastern Michigan - DMC CampusVibra Hospital of Southeastern Michigan - Taylor CampusVibra Hospital of the Central DakotasVibra Hospital of Western Massachusetts - Central CampusVibra Rehabilitation Hospital of AmarilloVibra Specialty Hospital of Portland

Practitioner Last Name

Practitioner First Name

Practitioner Degree

Practitioner NPI#

Practitioner Specialty

Practitioner State License # (State where privileges are being requested)

Practitioner's Email

Supervising Physician Name (for PA or NP only)

Will practitioner be providing telehealth services only?
YesNo

Will Vibra Healthcare be providing malpractice insurance?
YesNo

Authorized User First & Last Name (Office manager/assistant to help complete the application - optional)

Authorized User Email (optional)

Additional information (optional)

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