Physician Application Request

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 Letter (Click HERE)

Medical Staff Request for Application (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. You may send you application and the requested documents by email or mail:
    • Email:
    • Mail:     UH Samaritan Medical Center
           Sheri Beltz, Medical Staff Coordinator
           1025 Center St.
           Ashland, OH  44805

Contact Sheri Beltz with any questions at 419-207-2719 or