Physician ApplicationLet’s work together.All your information will remain confidential and secure. Name * First Name Last Name Gender * Male Female Email * HIPAA Compliant Email (if applicable) Phone * (###) ### #### Date of Birth * MM DD YYYY Social Security Number * EIN Please provide EIN & Entity if applicable. Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Medical Degree * MD DO Are you permitted to legally work in the United States? * (Y/N) Will you ever require work-visa sponsorship? * (Y/N) Are you a citizen of the United States? * (Y/N) What is your state of legal residence? * In what states do you have an ACTIVE medical license? * In what states do you have an inactive medical license? * Have you ever had a medical license revoked, suspended, or sanctioned? * (Y/N) Have you ever had hospital privileges suspended, or revoked? * (Y/N) Have you ever faced disciplinary action from a state or federal agency, program, medical board, or healthcare system? * (Y/N) Have you EVER had any malpractice claims? * (Y/N) Have you ever had any prior criminal convictions? * (Y/N) Have you had any malpractice claims within the last 10 years? If yes, please list claims and payout amounts as. If no, please write 'no'.* * Please provide 3-5 physician references * Complete first name, last name, specialty email address, and phone number. Please email a copy of an NPDB Report (within the last 6 months) to hello@SpecializedPhysicians.com. * Please acknowledge by checking this box Type full name as signature * By signing below you attest to the accuracy of the information above. Today's Date * MM DD YYYY Thank you!
