Physician Assistance Request Form

AMA members may use this form to request assistance in matters pertaining to their relationships with hospitals, health systems, and other similar entities. Please note that the AMA cannot provide legal opinions or representation.

Contact Information

*
Denotes a required field
First name
*
Last name
*
Hospital or health system affiliation 
 
 
City
*
State
*
Phone number
*
Are you an AMA member?
*
Yes
No

Physician Assistance Request Form

Question or Concern

*
Denotes a required field

Select the category or categories that best define your question or concern:

 
 
Medical staff appointment
 
 
Credentialing
 
 
Privileging
 
 
Peer review
 
 
Due process
 
 
Medical staff bylaws
 
 
Employment -- contracts
 
 
Employment -- other
Other question or concern:
 
Optional -- Describe your specific question or concern: 
 
 
How do you prefer to be contacted?
*
 
 
Email
Phone