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Physician Engagement Form

Please fill out the following form as completely as possible and hit the submit button when you have completed.
Identifying Information
Degree:

DO

Primary Specialty :
First Name:
Last Name:
SSN# (optional):
Date of Birth:
Address:
City/ State/ Zip:
Home Phone:
Cell Phone
Email Address:
NPI# (optional)
Best Time/Day to Reach:
Date Available
DEA # :
    
Board Certified:
 Yes No
Board Eligible
Yes No

Licensing
State License 1 :
 License # Exp:
State License 2 :
 License # Exp:
State License 3 :
 License # Exp:
State License 4 :
 License # Exp:
Disciplinary Actions
Have any of the following ever been or are currently in the process of being investigated, denied, revoked, suspended, reduced, limited, placed on probation, not renewed, been subject to disciplinary action or voluntarily relinquished? If Yes, please provide signed and dated explanation on a separate sheet.
       
Medical license in any state/ jurisdiction?
Yes No
DEA Registration?
Yes No
Other Professional Registration/License?
Yes No
Clinical Priviledges?
Yes No
Membership/rights on any Medical Staff?
Yes No
Institutional Affiliation/Status?
Yes No
Any Professional Sanction?
Yes No
Professional Society Membership or Fellowship/Board Certification Yes No
Participation in any Private, Federal or State Health Insurance Program? Yes No
Are you currently a Medicare/Medicaid Provider? Yes No       If Yes, #:
Are you currently a Provider of Private Insurance? Yes No     If Yes, which insurance:
 
Have you ever been convicted of a felony or misdemeanor? Yes No
Have you ever had your license or certification investigated, suspended, or revoked? Yes No
Have there ever been or are there currently any malpractice claims, suits, settlements, or arbitration proceedings involving your professional practice? Yes No
Have you ever been denied, gone without, or not maintained Professional Liability Insurance? Yes No
Do you currently have any medical condition or use any chemical substance which impairs or limits your ability to practice medicine with reasonable skill and safety? If Yes, provide evidence that such conditions do not currently impair or limit your ability to practice medicine in your specialty with reasonable skill and safety. Yes No
Within the past two (2) years, have you received treatment for alcoholism, drug abuse, or for any infectious disease, mental illness, or psychiatric problem which could impair or limit your ability to practice medicine in your specialty with reasonable skill and safety? If Yes, provide evidence that such conditions do not currently impair or limit your ability to practice medicine in your specialty with reasonable skill and safety. Yes No
Other than those circumstances noted above, is there anything in your personal or professional background that may surface during our credentials verification process that may be construed as derogatory or negative? Yes No
If you answered yes to any of the above questions please attach an explanation letter.
Physician Documents
Attach Your CV
Attach Letters of Reference
Provider Engagement Agreement

This engagement agreement is between the PROVIDER and NEXT MEDICAL STAFFING “AGENCY”.  As an independent contractor, PROVIDER is not an employee of AGENCY, and agrees that PROVIDER is responsible for his/her own medical decisions and actions.  During the term of this agreement (for two years), PROVIDER agrees to hold confidential any client or job opportunities introduced to PROVIDER by AGENCY.  PROVIDER agrees not to accept assignment or engage directly with any client introduced by AGENCY, and will work exclusively with AGENCY on opportunities introduced by AGENCY for the two year period.  

I attest that all statements in this application are true and accurate to the best of my knowledge. I understand that any falsification could lead to disciplinary action and/or termination of employment. I authorize Next Medical Staffing to contact past employers and references in order to verify the information I have provided. I release all such persons from liability for furnishing said information. I authorize Next Medical Staffing to release a copy of this application and any supporting information (medical references, background search results, etc.) which may be relevant to my employment to their client facilities.
* I agree with the above statements.
 

 

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