PHYSICIAN APPLICATION FOR EMPLOYMENT

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1 PLEASE COMPLETE The Following. DATE Name Last First Middle Maiden Address City State Zip Date of Birth Place of Birth Social Security Number US Citizen Home Phone Address Specialty/Sub-specialty Opportunity Sought: Education and Training (graduate and beyond) Medical School: Degree: Internship Residency P 1 of 7

2 Additional Education/training Additional Education/training ECFMG certificate number: Valid indefinitely? If no, state expiration date: Specialty Board: Expiration Date: (mm/yy) Board Certified Board Eligible P 2 of 7

3 Clinical Certifications: BLS Expiration date: ACLS Expiration date: ATLS Expiration date: PALS Expiration date: Other: Expiration date: Federal Provider Information: Federal DEA number: Expiration Date: NPI Medicare number: Medicaid number: State Licensure: State License # Date Issued Exp Date CSR CSR Exp Date P 3 of 7

4 Do you currently carry personal medical malpractice coverage? Yes No Name of Carrier: Telephone number: Policy number: Are you registered in the CAQH Universal Provider Datatsource? In addition to English, list other languages spoken with communication ease and /or fluency. Disciplinary Action: Please read carefully and answer the questions below; every yes response requires a written explanation. For disciplinary reasons, have any of the following (questions 1-10) ever been, or are they in the process of being either on a voluntary or involuntary basis - conditional, denied, revoked, suspended, reduced, limited, placed on probation, not renewed, withdrawn, or relinquished while under investigation or after being notified that investigation would be conducted? Questions Yes/No Explanation Medical license in any jurisdiction? Other professional registration/license? Federal DEA registration? State controlled substance registration? Academic appointment? Board certification? Clinical privileges? P 4 of 7

5 Membership/rights on any medical staff? Participation in Medicare/Medicaid programs? Participation in other health care organization (HMO, PPO, etc.)? Have you ever been convicted of a felony or entered into a plea for any criminal offense (excluding parking tickets)? Have you ever been placed on probation or taken a leave of absence from a medical or dental school, or post-graduate training program? Were you the subject of any disciplinary action during your periods of education or training? Have you ever been discharged from any position? Have you ever resigned or retired from a position after being notified you would be disciplined or discharged? Have there ever been or are there currently pending any malpractice claims, suits, settlements, or arbitration proceedings filed against you? Have you ever been denied or not maintained professional liability insurance? Have you ever had any problems with your health status which would interfere with your ability to practice your profession with reasonable skill and safety? Within the past five years, have you received treatment for drug or alcohol abuse, or for any psychiatric problem, which would affect your ability to practice your profession with reasonable skill and safety? Is there anything additional in your personal or professional history which could impede your ability to receive or maintain clinical privileges or medical licensing? P 5 of 7

6 References Please list four physicians (one must be supervisor) with whom you have worked over the past 12months who are able to comment on your clinical and professional competency. Date of Date of Date of P 6 of 7

7 Date of Attestation and signature: I hereby certify that the information contained in this application, including all attachments, is true and correct to the best of my knowledge. I acknowledge that Convergence Medical Staffing will rely on the truthfulness and accuracy of my curriculum vitae, and on the truthfulness and accuracy of the information and attestations contained in this application, in evaluating my potential as an independent contracting physician for positions of locum tenens or permanent employment. I further acknowledge that Convergence Medical Staffing is under no obligation to accept me as a candidate and does so at its sole discretion. Applicant s name: Signature: (See below for signature instructions) Date: INSTRUCTIONS: 1. Complete all editable fields 2. Print form 3. Sign on Signature line 4. Scan into a PDF file format 5. Attach PDF file to an and here or fax to: Please complete this form and or fax to Convergence Medical Staffing. Fax: Include the Physician Application and Physician Release & Waiver forms. P 7 of 7

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