Physician Recruitment Pre-Application Form

First Name:

Middle Name:

Last Name:

Address:

City:

State:

Zip Code:

Phone Number:

E-mail Address:

Social Security Number:

Country of Citizenship:

Current VISA Status:

Position Interviewing For:

In the Specialty of:

Current Professional Position:

Dates in Current Professional Position:

Current Board Certification Status:





Specialty or Specialties:

If not certified, have you taken the Board exam?:





If not certified, have you failed the Board exam?:





If not certified, are you scheduled to sit for the Board exam?:





If Yes , when are you scheduled? (example: mm/dd/yyyy):

If you have not taken the Board exam, have you been accepted to take the Board exam?:





Current and all previous states of medical licensure with numbers: (mark a C by all current licenses):


Do you have a current DEA certification number?:





If Yes, please provide DEA number:

If the answer to any question below is Yes, please provide a full explanation in the additional comments section. Have you ever been allowed to resign your employment, medical staff appointment, and/or any clinical privileges, rather than face any charge or investigation?:




Have you ever been excluded from providing services in any federal health insurance program (i.e. Medicare, Medicaid, etc.)?:




Do you have any medical malpractice liability suits or claims pending?:




Have you ever been convicted of a felony or crime of moral turpitude?:




Has any hospital ever denied, restricted, suspended, or revoked your privileges; have you ever voluntarily surrendered your privileges; or has probation ever been invoked?:




Has your narcotics or medical license ever been suspended, restricted, revoked, or voluntarily surrendered, or has probation ever been invoked?:




Have you ever been evaluated or recommended for treatment for, diagnosed with, or treated for alcohol, narcotics or any other substance abuse, sexual addiction or mental health?:




Have you ever been asked to participate in or have you volunteered to participate in an impaired physician program? (If Yes, please E-mail us a copy of your recovery plan):




If Yes to the question above, what was your participation?:





Have you ever been denied a medical license or been denied certification by a specialty board?:




Have you ever had any claims of sexual misconduct made against you?:




Have you ever had your request for malpractice coverage denied, your policy canceled or non-renewed or had a policy issued to you that contained restrictions or special exclusion?:




Has a patient or his representative ever filed a complaint or grievance against you with a hospital/committee, state licensing or regulatory agency or other medical review committee?:




Other than a minor traffic offense, have you ever been convicted of or pled guilty to or entered into a plea agreement for a violation of any law or ordinance?:




In the past twelve months, have you had any injury, illness, or other event occur that may impair, lessen or diminish your physical or mental ability to practice medicine?:




Have you ever appeared before, been investigated by, or entered into any consent agreement with any formal hospital committee, state licensing Board, Board of Medical Examiners, or other medical review committee?:




Have any claims or suits ever been made or brought against you?:




Indicate number of previous claims or suits (include closed, dismissed, and/or dropped cases):

Indicate number of pending claims or suits:

Do you have any knowledge of any claims which might be made against you (other than those indicated above) or activities that might reasonably give rise to a claim or suit being brought against you even if you believe the claim or suit would be without merit? (include any requests for medical records.):




Additional Comments:


Give the names of three professional references not related to you, whom you have known for at least 12 months.
Reference #1 Name:

Title:

Phone:

Reference #2 Name:

Title:

Phone:

Reference #3 Name:

Title:

Phone:

By clicking Submit , I certify that the above information, the information provided on my Curriculum Vitae are complete and truthful as of this date, and I will request a self-query from the National Practitioner Data Bank and direct it to: Davis Health System, Attn: Amy C. Yokum, Medical Staff Liaison, P.O. Box 1697, Elkins, WV 26241. The Data Bank can be contacted via the Internet at: www.npdb-hipdb.com or NPDB Customer Service at: 1-800-767-6732. By clicking Submit it also authorizes the Davis Health System Physician Recruitment Staff or its Physician Leadership to contact as applicable my Residency and/or Fellowship Training Director and/or the following Professional References: Residency and/or Fellowship Training Director with Contact Information: