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Physician Application

Please fill out the following secure online application as completely as possible. When completed hit the submit button at the bottom of the page.
Identifying Information
Degree:

DO

   
First Name:
Middle Name:
Last Name:
SSN# (optional):
Current Address:
City/ State/ Zip:
Permanent Address:
City/ State/ Zip:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Best Time/Day to Reach:
NPI# (optional)
Other names you have
been employed under:
    

Discipline:
Other/Sec. Discipline:
Date Available:
Current Specialty :
 
 
Emerg. Contact:
Relationship:
Phone:
Address:
City/State/Zip
    
Are you a U.S. citizen:
 Yes No  
If no, can you submit verification of your legal right to work in the U.S: Yes No
How did you hear about us:
Professional License
State
License #:
Date Issued:
Exp Date :
Controllled Substance Permit #
State
License #:
Date Issued:
Exp Date :
Controllled Substance Permit #
State:
License #:
Date Issued:
Exp Date :
Controllled Substance Permit #
State:
License #:
Date Issued:
Exp Date :
Controllled Substance Permit #
Professional Certifications
Certification Board:
Certification Board:
Date Certified:
Date Certified:
Date Certified:
Date Certified:
Recertification Date:
Recertification Date:
Clinical Certifications
BLS Certification:


Exp Date:
ACLS Certification:
Exp Date:
ATLS Certification:
Exp Date:
PALS Certification:
Exp Date:
DEA Registration
DEA Registration?
Registration #
Date Issued:
Exp Date:
Registration #
Date Issued:
Exp Date:
Registration #
Date Issued:
Exp Date:
If you do not currently possess a DEA Registration, please explain:
Pre-Medical Education
School Name/Institution::
City/State:
Date of Graduation:
Degree/Certifications:
Honors Received:
 
       
Medical Education
School Name/Institution::
City/State:
Date of Graduation:
Degree/Certifications:
Honors Received:
 
       
Internship
Type:
City/State:
Institution::
Program Director:
Date From:
Date To:
       
Residency
Type:
City/State
Institution::
Program Director:
Date From:
Date To:
       
Additional Residency or Fellowship
Type:
City/State
Institution:
Program Director:
Date From:
Date To:
       
Affiliations
Facility/Practice:
Date From:
 Date To:
Capacity:
Street:
City/State/Zip:
 
Facility/Practice:
Date From:
 Date To:
Capacity:
Street:
City/State/Zip:
 
Employment History

Please list all of your employment for the past ten (10) years beginning with your most recent employer. Please list each facility in which you have worked.

Are you currently employed now?
If so, may we contact your present employer?

Facility/Employer Name::
Unit/Floor/Dept.
City/State/Zip:
    
Start Date::
End Date:
Reason for Leaving:
Position Held:
Discipline
Unit Specialty:
Travel Assignment:
 Yes No
Travel Company:
Local Staff Agency:
 Yes No
Facility/Employer Name::
Unit/Floor/Dept.
City/State/Zip:
    
Start Date::
End Date:
Reason for Leaving:
Position Held:
Discipline
Unit Specialty:
Travel Assignment:
 Yes No
Travel Company:
Local Staff Agency:
 Yes No
Facility/Employer Name::
Unit/Floor/Dept.
City/State/Zip:
    
Start Date::
End Date:
Reason for Leaving:
Position Held:
Discipline
Unit Specialty:
Travel Assignment:
 Yes No
Travel Company:
Local Staff Agency:
 Yes No
Facility/Employer Name::
Unit/Floor/Dept.
City/State/Zip:
    
Start Date::
End Date:
Reason for Leaving:
Position Held:
Discipline
Unit Specialty:
Travel Assignment:
 Yes No
Travel Company:
Local Staff Agency:
 Yes No
       
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 relinquised? If yes, please provide signed and dated explanation on a separate sheet.
Medical License in any state/jurisdiction? Yes No DEA Registration? Yes No
If yes, please explain: If yes, please explain:
Other Professional Registration/License? Yes No Clinical Priviledges? Yes No
If yes, please explain: If yes, please explain:
Membership/Rights on any Medical Staff? Yes No Institutional Affiliation/Status? Yes No
If yes, please explain: If yes, please explain:
Any Professional Sanction? Yes No
If yes, please explain:
Professional Society Membership or Fellowship/Board Certification? Yes No
If yes, please explain:
Participation in any Private, Federal or State Health Insurance Programs? Yes No
If yes, please explain:
Have you ever been convicted of a felony or misdemeanor? : Yes No
If yes, please explain:
Have there ever been or are there any currently pending, any malpractice claims, suits, settlements, or arbitration proceedings involving your professional practice? Yes No
If yes, please explain:
Have you ever been denied, gone without, or not maintained Professional Liability Insurance? Yes No
If yes, please explain:
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? Yes No
If yes, please explain:
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 your ability to practice medicine in your specialty with reasonable skill and safety? Yes No
If yes, please explain:
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 yes, please explain:
Please list a minimum of three professional references with whom you have worked in the past two years and who will confirm a more detailed reference of your specific medial abilities:
1. Name:
Position:
Association
Phone:
Facility:
City/State:
Zip
Email:
 
 
 
 
2. Name:
Position:
Association
Phone:
Facility:
City/State:
Zip
Email:
 
 
 
 
3. Name:
Position:
Association
Phone:
Facility:
City/State:
Zip
Email:
 
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 one year), 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 one 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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