Personal Information First Name Last Name Middle Name Suffix Home Phone Work Phone Cell Phone Email Address Date of Birth (mm/dd/yyyy) Place of Birth (City, State, Country) SSN Are you legally able to work as an independent contractor in the United States? Emergency Contact Name Relationship Phone Number Email Address Education Name of Undergrad School Degree Start Date City State/Provence Zip Code Country Completion Date Post Graduate Training 1 P age Initials Date
Accreditation Is your training APA accredited? Other Certifications BLS ACLS ATLS PALS Other Military Service Military Branch Dates of Service (mm/dd/yyyy) Type of Discharge From: To: Licenses and Identification State License # Date Issued Controlled Substance Date Issued DEA # Date Issued 2 P age Initials Date
Hospital Privileges (List within the last 10 years) Type of Privileges From To Active Type of Privileges From To Active Type of Privileges From To Active Type of Privileges From To Active Type of Privileges From To Active Locum Tenens Experience (List within the last 5 years) Hospital Name/Clinic Name City From To Hospital Name/Clinic Name City From To Hospital Name/Clinic Name City From To Hospital Name/Clinic Name City From To Hospital Name/Clinic Name City From To Please remember to Initial and Date every page. 3 P age Initials Date
Questionnaire If you answer Yes to any of the following questions, provide 1 st and 3 rd party documentation and include the documentation with this application. 1. Have you ever been denied certification by a Specialty Board or not been allowed to take an exam for any reason? 2. Have any of your licenses, active or inactive, past or present, ever been limited, suspended, revoked, surrendered, reprimanded, admonished, placed on probation, investigated or placed under any other corrective action? 3. Have you ever been denied a medical license by any licensing board, or have you withdrawn an application for a medical license for any reason? 4. Has your DEA/Narcotics license ever been suspended, revoked, limited, voluntarily surrendered, or placed on probation? 5. Have you ever been denied membership or renewal thereof or been subject to disciplinary action by any medical organization or entity? 6. Have you ever failed to satisfactorily complete any portion of any training program? 7. Have you ever been terminated from employment or while working as an independent contractor? 8. Have you ever been sanctioned or investigated by Medicare and/or Medicaid? 9. Have your hospital privileges ever been denied, suspended, revoked, withdrawn or placed under any disciplinary actions, or have they ever not been renewed for any reason other than your own voluntary decision not to practice at that particular facility and/or time? 10. Have you received treatment for substance abuse or alcoholism? 11. Have you ever been convicted of a felony offense? Professional Liability If you answer Yes to any of the following questions, please complete a supplemental form for each claim and attach 3 rd party documentation from your malpractice carrier, attorneys, NPDB query or any other viable source. 1. Have there been or are there any current pending investigations, allegations, settlements or arbitration proceedings involving alleged malpractice relating to your professional practice? If yes how many? 2. Have you had any malpractice suits dismissed, settled, or closed without payment? If yes how many? 3. Have you had any malpractice suits dismissed, settled, or closed with payment? If yes how many? 4. Are you currently the subject in any pending medical malpractice claims or suits? If yes how many? 5. Have you ever been denied malpractice insurance? If yes, please explain: 4 P age Initials Date
Professional Liability History Present or Previous Insurance Carrier Start Date Present or Previous Insurance Center Start Date Present or Previous Insurance Carrier Start Date Referrals Please list any colleagues that may be interested in locum tenens. * Referral Bonus is paid after provider has worked 20 days / 160 hours if referred provider has never worked with. Consent I confirm that the information provided on this application is true and complete. I understand that, LLC will use this information to determine my qualifications to be approved for medical malpractice insurance and eligibility for locum tenens assignments or placements through, LLC. I acknowledge misinformation, omissions, or misrepresentation, intentional or not, will be just cause for immediate disqualification. I agree to hold, LLC and its staff harmless from any and all claims, actions, damages, judgments, accusations, and expenses arising from their acts in connection with the procuring, verification, and distribution of information provided by me in evaluation of this application, credentials, and qualifications. My signature below verifies that I accept the terms and conditions described above and I submit this Independent Contractor Application for consideration with LLC. X Provider Signature Print Name Date (mm/dd/yyyy) 5 P age