NURSE PRACTITIONER/PHYSICIANS ASSISTANT APPLICATION GENERAL INFORMATION. Last Name First Middle. Place of Birth Social Security #

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1 Page 1 NURSE PRACTITIONER/PHYSICIANS ASSISTANT APPLICATION GENERAL INFORMATION Last Name First Middle Place of Birth Social Security # Home Address City State Zip Office Address City State Zip DOB Emergency Contact Relationship Home Phone Cel Phone Office Phone Fax Specialties for locum tenens assignments: Primary Secondary UNDERGRADUATE TRAINING College or University Degree City State From: (M/Y) To: (M/Y) Did you complete the above program? Yes No if no, explanation PROFESSIONAL EDUCATION/TRAINING College or University Degree City State From: (M/Y) To: (M/Y) Did you complete the above program? Yes No if no, explanation NATIONAL CERTIFICATIONS (please include copies of board certification) Are you currently Board Certified? Yes No Name of Specialty Board Date of Original Certification: Date of Re-Certification: Have you ever taken a specialty board examination and failed to pass? Yes No If yes, how many times Have you ever applied for the certification exam? Yes No If yes, when is it scheduled? Provider Name (please print):

2 Page 2 LIST ALL STATES IN WHICH YOU HAVE BEEN OR ARE LICENSED (please include copies of all current licenses) State License # Date Issued Expiration Controlled Substance Permit # Date Issued Expiration Federal DEA Number Date Issued Expiration HOSPITAL AFILLIATIONS (Please put in chronological order, beginning with the most recent. Attach additional sheet if necessary) Name of institution City/state Position/Capacity Dates (Month/Year) Work History (Please put in chronological order, beginning with the most recent. Attach additional sheet if necessary) MILITARY SERVICE Did you serve in the military? Yes No Branch Discharge Date Status Provider Name (please print):

3 Page 3 PROFESSIONAL LIABILITY INSURANCE (Please complete in full if applicable) Present Carrier Policy # Phone # Coverage Limits Effective Dates_ Expiration Date Address City State Zip Code Past Carrier Policy # Phone # Coverage Limits Effective Dates_ Expiration Date Address City State Zip Code Past Carrier Policy # Phone # Coverage Limits Effective Dates_ Expiration Date Address City State Zip Code PROFESSIONAL REFERENCES List colleagues who can attest to your professional competence and clinical skills within the past 2 years. Two of the references must be from the same discipline and specialty (Please complete all sections entirely) (1)Name Poistion/Relationship Phone Address City State Zip Address Specialty Fax Worked with: From to (2)Name Poistion/Relationship Phone Address City State Zip Address Specialty Fax Worked with: From to Provider Name (please print):

4 Page 4 (3)Name Poistion/Relationship Phone Address City State Zip Address Specialty Fax Worked with: From to (4)Name Poistion/Relationship Phone Address City State Zip Address Specialty Fax Worked with: From to FITNESS FOR POSITION Yes No 1. The essential function of a locum tenens Provider is to provide a standard of care that is acceptable within his/her specialty. Are you capable of performing this function with or without reasonable accommodation 2. Are you authorized to work as an independent contractor within the United States? 3. Are you currently abusing alcohol, illegal drugs, or failing to take legally prescribed drugs in the manner prescribed? 4. Have you abuse alcohol, illegal drugs, or failed to take legally prescribed drugs? If yes, what drugs, and how recently have you used these illegal drugs: MALPRACTICE INFORMATION (if answer is yes, complete a Professional Liability Supplemental Claims form for each action) 1. Have there been or are there any pending malpractice claims, suits, judgments, settlements, or arbitration proceedings, or notices of intent to commence action involving you and/or your medical practice? Yes No Provider Name (please print):

5 DISCIPLINARY ACTIONS (please attach an explanation for any yes answer) Page 5 1. Have you ever been convicted of a felony misdemeanor? (A yes answer will not automatically disqualify you from consideration for placement on Integrity Locums roster or eligible providers. Factors such as when the offense was committed and the seriousness and nature of the offense will be considered) 2. Have you ever been convicted of any violation of a state or federal law relating to controlled substances? (A yes answer will not automatically disqualify you from consideration for placement on Integrity Locums roster or eligible providers. Factors such as when the offense was committed and the seriousness and nature of the offense will be considered) 3. Have you ever been denied or surrendered a state or federal controlled substance certificate? 4. Has your license to practice medicine in any state been reprimanded, sanctioned, placed on probation curtailed, suspended, revoked, restricted, denied or voluntarily surrendered? 5. Have you ever been denied a certificate by, or the privilege of taking an examination before any medical board? 6. Have your staff/clinic privileges at any hospital, health care facility, or clinic been denied, revoked, suspended, curtailed, limited, reduced, or placed under conditions restricting your practice? 7. Have you ever been terminated from employment? 8. Have you ever been disciplined by any state board for any violation of the medical practice art or unethical conduct? 9. Have you ever been denied provider participation in any state of federal Medicare or Medicaid program? 10. Have you ever been terminated, sanctioned, penalized or had to repay money to any state or federal Medicare/Medicaid programs? 11. Have you ever been the subject of any investigative or disciplinary proceedings or reprimanded by a governmental or administrative agency? 12. Have you ever been convicted of a violation of any federal or state narcotic laws? (A yes answer will not automatically disqualify you from consideration for placement on Integrity Locums roster or eligible providers. Factors such as when the offense was committed and the seriousness and nature of the offense will be considered) 13. Have you ever been disciplined by a hospital staff, internship or residency program? 14. Is there any other issue, which should be disclosed that may have an adverse impact on your ability to deliver effective locum tenens provider services? NO CONSENT I hereby affirm and acknowledge that the information provided by me on this application and the attachments is true, complete and correct, and that Integrity Locums Recruiting doing business as Integrity Locums will rely on the truthfulness of my statements in evaluating my potential to be placed with Integrity Locums clients as a locum tenens provider. I hereby release Integrity Locums its staff, agents and representatives from liability for their acts performed in good faith and without malice in connection with evaluating my application, credentials and qualifications. I further release from liability providers, hospitals and other references for the good faith release of information regarding my professional capabilities and performances. I acknowledge that the decision to place me on the roster of eligible providers for placement as a locum tenens provider is solely at the discretion of Integrity Locums I further acknowledge that I will not enter into an arrangement to provide temporary or permanent physician services with any individual, group or institution to whom I am referred by Integrity Locums except through Integrity Locums or with Integrity Locums consent. By providing your name, signature and phone numbers you are consenting to receive phone calls from Integrity Locums and its affiliates regarding our services. Yes No Provider Signature Date ALL QUALIFIED APPLICANTS RECEIVE CONSIDERATION WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, AGE, NATIONAL ORIGIN, DISABILITY, MARITAL STATUS, VETERAN STATUS OR ANY OTHER LEGALLY PROTECTED STATUS.

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