Please answer each of the following questions, attaching additional sheets as necessary. The Applicant understands
that information sought for review herein is elicited to maintain the quality of healthcare services provided by
Reliant Medical Group through a complete evaluation of those seeking employment. The questions and answers
below are considered CONFIDENTIAL peer review information, and will be used solely for those purposes.
1.
Name:
Title:
Other Name (including any maiden, married or other names under which you may have been granted a
professional license in the past):
2.
Date of Birth:
(Required field to access NPDB)
3.
Licensure
Please identify each state in which you have ever held a training or unrestricted license to practice include
numbers and expiration dates (include active and inactive):
State:
Number:
Expiration Date:
State:
Number:
Expiration Date:
State:
Number:
Expiration Date:
State:
Number:
Expiration Date:
State:
Number:
Expiration Date:
State:
Number:
Expiration Date:
4.
If you do not have a state license to practice medicine, have you passed all three parts of the USMLE?
Yes
No ? (If no, please attach an explanation.)
5.
DEA number:
Expiration Date:
6.
SSN:
ECFMG Number:
(required field to access NPDB)
NPI Number:
(Required field to access NPDB)
7.
Place of Birth:
8.
Citizenship:
Visa Status:
9.
EDUCATION
Undergraduate:
College/University
Degree
Location
Month & Year Program Began
College/University
Degree
Month & Year of Graduation
Location
Month & Year Program Began
Month & Year of Graduation
Graduate:
College/University
Degree
Location
Month & Year Program Began
College/University
Degree
Month & Year of Graduation
Location
Month & Year Program Began
Month & Year of Graduation
Medical:
Medical/Professional School
Degree
10.
Location
Month & Year Program Began
Month & Year of Graduation
Internships, Residencies, Fellowships, Preceptorships/Teaching Appts. (Please list chronologically)
Program
Month & Year Began- Location
Month & Year Completed
Program
Month & Year Began- Location
Month & Year Completed
Program
Month & Year Began- Location
Month & Year Completed
Program
Month & Year Began- Location
Month & Year Completed
Program
Month & Year Began- Location
Month & Year Completed
11.
Work History and Institutional Affiliations
Please list your current employer. This includes all hospitals, corporations, military assignments, or
governmental agencies. Complete addresses must be included.
From: Month & Year
To: Month & Year
Institution:
Address:
Department Chief:
Staff Category:
12.
Do you currently hold active Board Certification or its equivalent?
Yes
No , if no when will you be Board Eligible?
Board Name: _______________________________________________________
Specialty: __________________________________________________________
Date Certified: ______________________________________________________
13.
Professional Questions
Have you ever been, or are you currently, subject to any of the following. Any “yes” answers, please
provide details in an attachment.
A. Probation, suspension, or revocation of your license to practice medicine in any jurisdiction of the
United States, or in any country or territory in which any such license was held?
Yes
No
B. To your knowledge are you currently under investigation by any licensing board or agency in any
jurisdiction?
No
Yes
C. Denied any Hospital Medical Staff appointment?
Yes
No
D. Exclusion from any other program of health insurance, including Blue Shield or Blue Cross
progams?
Yes
No
E. Exclusion from any funds to any governmental or third-party Payor?
Yes
No
F. Repayment of any funds to any governmental or third-party Payor?
Yes
No
G. A sanction or requirement to have remedial medical education by any Peer Review
Organization?
Yes
No
H. Have you ever been a defendant in a professional liability action?
Yes
No
I. Have you ever paid any claim in settlement of a professional liability action, or had any claim
paid on your behalf by a malpractice insurance carrier?
Yes
No
J. Have you ever been a plaintiff or defendant in any other civil action (excluding any domestic
relations or divorce proceedings)?
Yes
No
K. Do you know of, or anticipate any professional liability actions outstanding or likely to be filed
that might include you?
Yes
No
L. Is there anything we have not discussed that might pose difficulties in obtaining state licensure or
medical staff privileges?
Yes
No
How did you hear about this Position?
References
Name:
Telephone:
Position/Location:
Professional References: Reliant Medical Group requires that we have 3 professional references (must have had
direct clinical observation of you in your intended scope of practice within the last 2 years) prior to your interview;
however, we ask you provide 5 in the event we are unable to contact one. For those in training, one reference MUST
be the Program Director.
1.
Name
Title
Organization
City/State
Relationship
Phone
Fax
Email
Fax
Email
Fax
Email
2.
Name
Title
Organization
City/State
Relationship
Phone
3.
Name
Title
Organization
City/State
Relationship
Phone
4.
Name
Title
Organization
City/State
Relationship
Phone
Fax
Email
Fax
Email
5.
Name
Title
Organization
City/State
Relationship
Phone
Release Authorization
I hereby authorize and consent to a full investigation by Reliant Medical Group and its agents, for the purpose
of determining my professional and ethical qualifications and/or competence for the position for which I am
applying. Such investigations may include inquiring from such hospitals and staffs with which I am or have
been associated as a member or otherwise and insurers with which I am or have been insured for professional
liability and inspection of any disciplinary files or other relevant information.
Pursuant to this authorization and consent, I agree to hold harmless from any judgments, damages, legal liability
and/or legal costs incurred by any person or entity, or agent thereof, either seeking or providing information
regarding my professional and ethical competence and/or qualifications, so long as such information is sought
or provided in good faith and without malice.
Provider Name
Date
By typing your name above you agree that this is valid as your signature
Workforce Diversity
Equal Opportunity / Affirmative Action Analysis
As a government contractor, Reliant Medical Group, is subject to Executive Order 11246, as amended; and
Section 402 of the Vietnam Era Veterans Readjustment Assistance Act of 1974. All of these require
government contractors to take affirmative action in the employment process,
We request your assistance in the completion of the following questionnaire to be used ONLY for the
purpose of monitoring the success of our Affirmative Action Plan; this information will be kept
confidential.
Name: ____________________________________________________________________ Sex: Male
Female
Ethnicity: (please check below)
White (W)
(Not of Hispanic origin) A person having origins in any of the original peoples of Europe, North Africa
or Middle East.
Black (B)
(Not of Hispanic origin) A person having origins in any of the black racial groups.
Asian or Pacific Islander (A)
A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian
continent; or the Pacific Islands. This includes, for example China, Japan, Korea, India, Pakistan,
Bangladesh, Sri Lanka (formerly Ceylon), Nepal, Sikkim, Bhutan, Afghanistan, The Philippine Islands,
and Samoa.
American Indian or Alaskan Native (AI)
A person having origins in any of the original peoples of North America and who maintains cultural
identification with Tribal affiliation or community recognition.
Hispanic (H)
A person of Mexican, Puerto Rican, Cuban, Central or South American culture or other Spanish culture
or origin regardless of race.
Cape Verdean (V)
A person having origins in the Cape Verde Islands.