Medical/Dental Professionals

Medical/Dental Staff Application

In order to receive privileges at Kaleida Health, applicants are required to complete the Medical/Dental Staff Application form and an online learning tutorial (in Step 4).

Please refer to the FAQ section if you have questions on the application process. If you need assistance please call the Medical Staff Office at (716) 859-5501.


Before you begin instructions!

  1. Create a   folder on your computer/desktop called "Kaleida Health Application". This is where you will save all PDFs and scanned documents during the application process.
  2. Review check list and gather the required documents that need to be scanned into your computer. If you are not able to scan documents, you will need to mail them as outlined below.

      Download MD Checklist  Download APP Checklist

  3. Upload a high resolution jpeg (300 dpi) passport size photo   to your computer.
  4. There will be some documents throughout the application that you will need to print, please be sure to have a printer available.
  5. Those documents requiring your signature are listed on the Kaleida Health signature attestation form (you will print the form; sign, date and add as an attachment with your application and jpeg photo).
  6. Select “print documents” (“print documents” will print only those additional documents that require your signature).

Send application by email

  1. Select “submit via email,” an email window may or may not open due to computer software available. If it does open, attach any documents at this time (please be sure that the scanned documents are legible). If it does not open, please go to your email client and start a new email with attachments to newapplications@kaleidahealth.org.
  2. Click send and your application will be delivered to the Medical Staff Office. You will receive an email in response confirming the receipt of your application.  Within 7-12 business days, you will receive an email outlining any additional requirements and/or missing information.

Send application by mail

  1. If you do not wish to submit your application electronically, select “PRINT ALL” to print the application and additional documents (this option should be used only if you are not going to complete the application electronically.)  

What are required documents?

Required documents are any documents that the MSO has requested copies of and the signature attestation page.

What if I need to save and return to complete the application? 

You MUST save the document to your computer.


Please follow the steps below to complete the application process

Attestation

The application contains several documents requiring the provision of information and your signature.

Please download the form below and sign:

  Download MD Signature Attestation  Download APP Signature Attestation

By signing the attestation form you are agreeing to all forms listed below:

  •  Background Check Form
  •  Professional Liability Claims Information Form
  •  Federal/Champus  Acknowledgement form (Physicians only)
  •  Physician Coverage Policy Form (Physicians only)
  •  Memorandum of Intent – Excess Liability Coverage Form (Physicians only)
  •  Continuing Medical Education (CME) Attestation Form
  •  Acknowledgement of Review of “The Role of CPH in Helping Impaired Physicians”

NYS Infection Control Certification

Mandatory Requirement

New York State regulations and the Medical Staff Bylaws (PDF) require that practitioners maintain a current New York State Infection Control Certification. You can update your certificate at mymedcerts.com. The course is valid for four years. Find more information at the Department of Health website.

Application

Please view this short introduction video (3min 27sec) regarding the application process.

Privileges

NOTE: Must complete Internal Medicine & Pediatric Delineation of Privileges (DOP) along with the corresponding subspecialty if applicable.

Additional Documents

Review Privileges

Review MD PrivilegesReview APP Privileges

Fee

Thank you for applying to become part of the Kaleida Health Medical/Dental Staff. As a convenience, you may pay your non-refundable appointment fee using any major credit card. Please complete the following information to finalize your application process.

MD/DO application processing fee:
$250

APP application processing fee:
$125

Payment Options:

Pay Application Fee Online

or Pay by Check

Please mail checks to:

Kaleida Health Medical/Dental Staff Office
1028 Main Street, 3rd Floor
Buffalo, NY 14202

Submitting Application Documents

Did you save all documents and the application to the folder on your computer/desktop called "Kaleida Health Application"?

  1.   Completed Application – (as an attachment)
  2.   KH Signature Attestation form
  3.   DOP or SOP
  4.   Copies of required documents
  5.   Application Fee (indicate if paid on line or check mailed)
  6.   Scanned Passport size photo (.jpg)

Where do I send my application?

Please choose an option below to send all documents, photo in jpeg format, and completed application:

Email

newapplications@kaleidahealth.org

Mail

KH Medical/Dental Staff Office
1028 Main Street, 3rd Floor
Buffalo, NY 14202

What happens after the application is sent?

When submitting applications via standard mail the processing and email response time will fall within 7-12 business days following the date the application is received by the Medical staff Office (MSO). Once the MSO begins processing your application you will receive an email from Courion@kaleidahealth.org. This email will provide you with your system user name and important instructions. Please add Courion@kaleidahealth.org to your email address book now, so that this important email does not go into your junk folder.

If your application is deemed incomplete (unanswered questions or omissions, including signature attestation form, on the application or if any of the required documentation is not submitted), the Medical Staff Office will notify you of the outstanding information required from you. Your application will also be deemed incomplete if the need arises for new, additional or clarifying information at any time during the application process.

Accreditation standards require verification of certain data with the primary source. This is accomplished by requesting verification directly from the individual or institution and requiring that their response be returned directly to our office. Information requiring primary source verification includes, but is not limited to, professional school graduation, postgraduate training, professional references, hospital affiliations, malpractice history and professional licenses. In addition, we query the National Practitioner Data Bank and the Office of Inspector General’s List of Excluded Individuals as part of consideration of any applicant. For your application to be considered complete, all information must be verified. Please remember it is ultimately the applicant’s responsibility to ensure that all information has been received.

Upon completion of the primary source verification, your application with all related verification and supporting documentation will be reviewed by the department Chief of Service. The Chief of Service will complete the privileging and decision making portion of the application process. The Medical Staff Office will notify you when your application and request for privileges has been approved. Completion of the application DOES NOT guarantee acceptance by Kaleida Health.

Thank you for your interest in Kaleida Health, you have now begun the application process. Our new application team will be reaching out to you via email and we look forward to your correspondence.

Kaleida Health Incentive "Gainsharing" Program

Kaleida Health has a quality improvement and cost-reduction program (Incentive Program or Program) that aligns our incentives with that of eligible physicians. The Program is intended to improve the efficiency of our delivery of inpatient medical and surgical services, while maintaining or improving the quality of care. The Incentive Program will compensate physicians who reduce inpatient resource utilization by eliminating medically unnecessary services. The Incentive Program, also known as “gainsharing,” applies to commercial and Medicare and Medicaid managed care patients only; it does not involve Medicare or Medicaid fee-for-service patients, due to legal constraints.

  Download Individual Form  Download Group Form


Kaleida Health Bundled Payment Shared Savings Program

The Kaleida Health Bundled Payment Shared Savings Program is intended to incentivize practitioners to participate in specified quality metrics, in order to improve the quality, patient experience and cost-effectiveness of care provided to applicable Medicare beneficiaries.

  Download Individual Form  Download Group Form