Bon Secours Health System- Newly Credentialed Physician

The purpose of this form is to request access to networked computer system(s) in Bon Secours Virginia. 

Required fields are noted with an asterisk (*). 

Facility *
 New Physicians On Boarding Applications (includes ADS, HealthStream, ConnectCare, PACS, Citrix, SoftMed, PACS, CC Orders, Lab IS Support, EDC Powerscribe and CC Document Management)
First Name *
Middle Initial *
Last Name *
Practice Name *
Clinical Practice Address (physical address only) *
Clinical Practice City *
Clinical Practice State *
Clinical Practice Zip *
Clinical Work Number *
Clinical Fax Number *
Email Address *
Job Title *
Provider Type *
Provider Specialty *
Provider Specialty (Secondary)
Staff Category *
Physician’s Department

ConnectCare Training Contact Information

Contact Name
ConnectCare Scheduling Phone Number
ConnectCare Scheduling Email Address
Anticipated Start Date
Richmond Academy Number *
DEA Number *
VA License *
NPI *
Additional Information-Other Applications
* required fields

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Bon Secours International| Sisters of Bon Secours USA| Bon Secours Health System