Request for Application

Click on the link below to open the Request for Application form and instructions for requesting an application to the Samaritan Medical Staff.

     Medical Staff Request for Application link (click here)

Instructions for completing Medical Staff Request for Application:

  1. Open application using link.
  2. Complete application electronically.
  3. Sign the document using a digital signature (you will be prompted to create a new digital signature or use an existing signature file).
  4. Save a copy of the document for your records (you will be prompted to save after affixing your digital signature).
  5. Click “Submit Application”.  The application will be submitted to Tammy Bragg, Medical Staff Secretary (tbragg@samaritanhospital.org).
  6. Send requested documents listed in the application to:
         Samaritan Regional Health System
         Tammy Bragg, Medical Staff Secretary
         1025 Center St.
         Ashland, OH  44805

If you do not wish to complete the application electronically, you may print and send the completed document to the above address.

Contact Tammy Bragg with any questions at 419-207-2447 or tbragg@samaritanhospital.org.

Folder: Physician