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MEDICAL STAFF EMPLOYMENT APPLICATION

We are committed to a policy of Equal Employment Opportunity and will not discriminate against an applicant or employee on the basis of race, color, religion, creed, national origin or ancestry, sex, gender identity, age, physical or mental disability, veteran or military status, genetic information, sexual orientation, marital status, or any other legally recognized protected basis under federal, state or local laws, regulations or ordinances. The information collected by this application is solely to determine suitability for employment, verify identity and maintain employment statistics on applicants.

Applicants with disabilities may be entitled to reasonable accommodation under the terms of the Americans with Disabilities Act and certain state or local laws. A reasonable accommodation is a change in the way things are normally done which will ensure an equal employment opportunity without imposing undue hardship on the Company. Please inform the Company's personnel representative if you need assistance completing any forms or to otherwise participate in the application process.

Please provide complete and legible information. An incomplete application may affect your consideration for employment.

PERSONAL

Last Name

First Name

Middle

Type
Address Line 1
Address Line 2
City
State
Postal Code
Country
Type
Number
Extension

E-mail Address

Are you legally authorized to work in the U.S.?
Yes      No

Do you now, or will you in the future, require immigration sponsorship for work authorization (e.g., H-1B)?  (if hired, verification will be required consistent with federal law.)
Yes          No

Are you at least 18 years old?  (if no, you may be required to provide authorization to work)
Yes      No
Willing to Relocate?
Yes      No

Have you previously been on staff or made an application for staff appointment here?

Yes      No

Have you ever been previously employed here?
Yes      No

If yes, list dates employed:

From:

To:

 

Do you have any relatives employed by this organization?
Yes      No 

If yes, give name and title.

How did you hear about us?

Employee Referral (name):

Corporate Website

Medical Journal (name):

Other:

Internet Site (name):

 

 

POSITION INFORMATION

Desired Type of Employment

Salary Range Expected

Date Available to Start

 

EDUCATION

MEDICAL or PROFESSIONAL SCHOOL

Institution Name

Degree Earned

Graduation Date

Address

City

State

If medical school was not in the United States, please indicate your ECFMG number:

INTERNSHIP:

Institution Name

Program

Address

City

State

Name of Program Director

Start Date

End Date

 

RESIDENCIES:  Those completed within the past 3 years will be contacted for a professional reference.

1. Institution Name

Program

Address

City

State

Name of Program Director

Program Director’s Phone

Start Date

End Date

 

2. Institution Name

Program

Address

City

State

Name of Program Director

Program Director’s Phone

Start Date

End Date

 

FELLOWSHIPS:  Those completed within the past 3 years will be contacted for a professional reference.

1. Institution Name

Program

Address

City

State

Name of Program Director

Program Director’s Phone

Start Date

End Date

 

2. Institution Name

Program

Address

City

State

Name of Program Director

Program Director’s Phone

Start Date

End Date

 

During your training were you ever suspended, placed on probation, formally reprimanded, or asked to resign?
Yes    No

   If “yes”, please provide details in the field below.

 

ACADEMIC APPOINTMENTS – List in chronological order, beginning with most recent.

1. Institution Name

Department

Address

City

State

Zip

Position

Start Date

End Date

2. Institution Name

Department

Address

City

State

Zip

Position

Start Date

End Date

3. Institution Name

Department

Address

City

State

Zip

Position

Start Date

End Date

 

PROFESSIONAL ASSOCIATIONS - Local, state, or national

 

1. Association Name

Membership Status

2. Association Name

Membership Status

3. Association Name

Membership Status

Has your membership in any professional society or association ever been cancelled, revoked or censured?
Yes    No

 

PROFESSIONAL PRACTICE - For the past five (5) years, list in chronological order, beginning with the most recent.

1. Name of Practice

Nature of Practice (e.g. solo, partnership, group, HMO, etc.)

Address

City

State

Zip

Title or Position

Start Date

End Date

2. Name of Practice

Nature of Practice (e.g. solo, partnership, group, HMO, etc.)

Address

City

State

Zip

Title or Position

Start Date

End Date

3. Name of Practice

Nature of Practice (e.g. solo, partnership, group, HMO, etc.)

Address

City

State

Zip

Title or Position

Start Date

End Date

4. Name of Practice

Nature of Practice (e.g. solo, partnership, group, HMO, etc.)

Address

City

State

Zip

Title or Position

Start Date

End Date

5. Name of Practice

Nature of Practice (e.g. solo, partnership, group, HMO, etc.)

Address

City

State

Zip

Title or Position

Start Date

End Date

 

HOSPITAL & INSTITUTIONAL AFFILIATIONS - List in chronological order, beginning with the most recent, including military service.

1. Institution Name

Department

Address

City

State

Zip

Status

Start Date

End Date

2. Institution Name

Department

Address

City

State

Zip

Status

Start Date

End Date

3. Institution Name

Department

Address

City

State

Zip

Status

Start Date

End Date

Have you ever resigned from a medical staff appointment, clinical privileges, or employment at any hospital or other health care facility?
Yes    No

Have your privileges, medical staff appointment or employment ever been denied, diminished, suspended, revoked, or refused at any hospital or other health care facility?
Yes    No

Have you ever voluntarily relinquished privileges or staff membership at any hospital or health care institution?
Yes    No

Have you been, or are you currently, under investigation by any hospital, professional association, or licensing agency?
Yes    No

Have any fee complaints or professional relations complaints been registered against you with your medical association, hospital, or licensing authority?
Yes    No

If you answered “yes” to any of the above questions, please give details in the field below.

 

LICENSURE - List all, past and present.

State

License Number

Year Issued

Status

State

License Number

Year Issued

Status

State

License Number

Year Issued

Status

Have any disciplinary actions ever been initiated, or are any pending against you by any state licensure board?
Yes    No

Has your license to practice in any state ever been limited, suspended, revoked, or voluntarily relinquished?
Yes    No

Have you ever appeared before a state regulatory review committee for alleged misconduct or malpractice?
Yes    No

If you answered “yes” to any of the above questions, please give details in the field below.

 

REGISTRATIONS

Federal DEA Registration Number

Year Issued

Expires (Year)

Texas DPS Registration Number

Year Issued

Expires (Year)

NPI#:

Has your narcotics registration certification ever been limited, suspended, revoked or voluntarily relinquished?
Yes    No

If “yes”, please give details in the field below.

 

BOARD CERTIFICATIONS

Name of Board

Date Certified (Year)

Date Recertified,  if applicable

Expiration Date,  if applicable

Name of Board

Date Certified (Year)

Date Recertified,  if applicable

Expiration Date,  if applicable

Name of Board

Date Certified (Year)

Date Recertified,  if applicable

Expiration Date,  if applicable

If not Boarded or Certified, select from the following options:

Have taken exam, results pending (date)

Intend to sit for the Boards on (date)

Have taken Part I of the exam; eligible to take Part II

Not planning to take Boards

Failed the Certification exam; please give details in the field below:

 

PROFESSIONAL LIABILITY DATA - For the past ten (10 years)

Current Liability Insurance Carrier

Address

City

State

Zip

Current Liability Policy Number

Policy Type (select one)
Claims-Made    Occurrence

Start Date

End Date

 

 

Previous Liability Insurance Carrier

Address

City

State

Zip

Current Liability
Policy Number

Policy Type (select one)
Claims-Made
Occurrence

Start Date

End Date

 

 

If you had a Claims Made policy, did you purchase “Tail Coverage”?
Yes    No
If “yes”, what were the limits?

Have any professional liability suits or claims ever been filed against you?
Yes    No

Have you ever been denied professional liability insurance coverage?
Yes    No

Has your professional liability insurance coverage ever been terminated by action of the insurance company?
Yes    No
If you answered “yes” to any of the above questions, please give details in the field below.

 

HEALTH STATUS

Do you have any condition(s) that would prevent you from performing the essential job duties of a healthcare provider?
Yes    No
If “yes”, please give details in the field below.

 

REFERENCES - Names and addresses of three (3) individuals who have direct knowledge of your training and/or experience or who have knowledge of your current clinical skills

Name

Current Company

Relationship

Phone

E-mail

Name

Current Company

Relationship

Phone

E-mail

Name

Current Company

Relationship

Phone

E-mail

 

ACKNOWLEDGMENTS - Please indicate that you have read and understand each statement below by placing a checkmark next to each paragraph.

I certify that this application was completed by me and that all entries on it and all information in it are TRUE and COMPLETE to the best of my knowledge. In the event of employment, I understand that false, misleading, or omitted information in my application may result in discharge.

I understand, where permissible under applicable state and local law, I may be subject to a pre-employment drug test after receiving a conditional offer of employment, and must receive a negative result for illegal drug use before being permitted to commence work with Company. I understand, where permissible under applicable state and local law, I may be subject to a pre-employment medical examination after receiving a conditional offer of employment, and must meet the qualifications for the position, with or without reasonable accommodation, before being permitted to commence work with Company. I agree to submit to a post-offer medical examination, including drug testing, if required, and understand that any offer of employment is contingent upon the results of that examination..

I further agree to observe all rules, regulations and policies of this organization.

I understand, where permissible under applicable state and local law, I may be subject to a pre-employment background check after receiving a conditional offer of employment to investigate my criminal background and other matters related to my suitability for employment.

I authorize this organization to investigate and verify all work references and statements placed on this application, and authorize this organization, its Medical Staff and their representatives to consult with my prior associates and others who may have information bearing on my professional competence, character, ethical qualifications, and ability to work cooperatively with others. My exceptions, if any, to this agreement and authorization are listed in the field below.  (If no exceptions, please write “none”).

I authorize this organization to contact the National Practitioners Data Bank, my professional liability insurance carriers, and others who may have information to verify my claims history, insurance coverage(s), and policy limits.

I understand that I must provide proof of all existing professional liability policies since I have been in practice, including tail coverage for any claims-made policies; and that it is my responsibility to pay for tail coverage prior to any employment with this organization.

I hereby release from liability any and all individuals and organizations that provide information to this organization or its Medical Staff concerning my professional competence, ethics, character, and other qualifications for Staff appointments and clinical privileges.

I understand that the information I am providing will be released by this organization to insurance companies, HMO, POS, and PPO carriers for credentialing purposes and I hereby release this organization from any and all liability for doing so.  I certify that the information herein provided is true and correct to the best of my knowledge and I hereby authorize this organization to release the information.

I understand that, in the event of employment, I will be accepting new patients in my practice at this organization.

I understand that the technical processing and transmission of the application, including my personal information, may involve (a) transmissions over various networks, including the transfer of this information to the United States and/or other countries for storage, processing and use by Company, its affiliates, and their agents; and (b) changes to conform and adapt to technical requirements of connecting networks and devices.  Accordingly, I agree to permit such parties to make such transmissions and changes, and hereby provide the necessary consent for the same.

State Specific Notices

Massachusetts Applicants: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liabilities.

Maryland Applicants: UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A POLYGRAPH EXAMINATION OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.

I certify that all of the above information is true and complete, and I understand that any falsification or omission of information may disqualify me from further consideration for employment or, if hired, may result in termination regardless of the time elapsed before discovery.

Applicant Name

Date Application Completed

Applicant Signature
(checking the checkbox above is equivalent to a handwritten signature)