One Hurley Plaza, Flint, MI 48503

Professional/Allied Health Staff Membership Application

Hurley Medical Center Application

Please:

  1. Complete this entire application.
  2. Curriculum Vitae will not be accepted as replacement for any part of this application.
  3. Ensure all items indicated in “red” are complete as they are mandatory.
  1. Personal Information

Last Name / Click here to enter text. / First Name / Click here to enter text.
Middle Name / Click here to enter text. / Degree/Professional Title / Click here to enter text. /
Other Names You May Have Used (Maiden, a.k.a., etc.) / Click here to enter text. /
Home Address/Street / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other” / Zip Code / Click here to enter text. /
Home Telephone Number / Click here to enter text. / Home Fax Number / Click here to enter text. /
Email Address / Click here to enter text. /
Date of Birth / Click here to enter text. / Citizenship/Place of Birth / Click here to enter text. /
Languages Fluently Spoken in Addition to English / Click here to enter text. /
Languages Written in Addition to English / Click here to enter text. /
Social Security Number / Click here to enter text. /
Ethnicity (Optional) / Click here to enter text. / Gender / ☐Male ☐Female
  1. Practice Specialty for Which You Are Seeking Affiliation

Are you applying as a:

☐Primary Care Physician / Click here to select Specialty

☐Specialist

Specialty / Click here to enter Specialty /
Sub-Specialty / Click here to enter Sub-Specialty. /
☐Allied Health Practitioner / Click here to select Specialty.
Other Medical Interests in Practice, Research, etc. / Click here to enter text. /

COPY THIS PAGE FOR MORE THAN ONE OFFICE

☐Information will be published unless box checked.

  1. PRIMARY OFFICE PRACTICE INFORMATION:

Group Practice Name as it Appears on SS4 or W9 Form / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / County / Click here to enter text. /
Mailing Address if Different Than Above (Newsletters, etc.) / Click here to enter text. /
Telephone Number / xxx-xxx-xxxx / Fax Number / xxx-xxx-xxxx /
Office Email Address / Click here to enter text. /
Emergency On-Call No. / xxx-xxx-xxxx / Beeper No. / xxx-xxx-xxxx /
Office Manager (OM) / Click here to enter text. /
OM Telephone No. / xxx-xxx-xxxx / OM Fax No. / xxx-xxx-xxxx /

List Physicians Practicing at This Location

Physician Name / Specialty
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II. CROSS COVERAGE (Please list covering practitioners. Please attach additional information (if applicable)
Name of Practitioner / Click here to enter text. / Specialty / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / Telephone No. / xxx-xxx-xxxx /
Name of Practitioner / Click here to enter text. / Specialty / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / Telephone No. / xxx-xxx-xxxx /
Name of Practitioner / Click here to enter text. / Specialty / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / Telephone No. / xxx-xxx-xxxx /
Name of Practitioner / Click here to enter text. / Specialty / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / Telephone No. / xxx-xxx-xxxx /
Name of Practitioner / Click here to enter text. / Specialty / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / Telephone No. / xxx-xxx-xxxx /
Name of Practitioner / Click here to enter text. / Specialty / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / Telephone No. / xxx-xxx-xxxx /
Name of Practitioner / Click here to enter text. / Specialty / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / Telephone No. / xxx-xxx-xxxx /
Name of Practitioner / Click here to enter text. / Specialty / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / Telephone No. / xxx-xxx-xxxx /
Name of Practitioner / Click here to enter text. / Specialty / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / Telephone No. / xxx-xxx-xxxx /
III. ALLIED HEALTH PRACTIONER SUPERVISING PHYSICIANS
Name of Supervising Physician / Click here to enter text. / Specialty / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / Telephone No. / Click here to enter text. /
Hospital Affiliations / Click here to enter text. /
Name of Supervising Physician / Click here to enter text. / Specialty / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / Telephone No. / Click here to enter text. /
Hospital Affiliations / Click here to enter text. /
Name of Supervising Physician / Click here to enter text. / Specialty / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / Telephone No. / Click here to enter text. /
Hospital Affiliations / Click here to enter text. /
Name of Supervising Physician / Click here to enter text. / Specialty / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / Telephone No. / Click here to enter text. /
Hospital Affiliations / Click here to enter text. /
Name of Supervising Physician / Click here to enter text. / Specialty / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / Telephone No. / Click here to enter text. /
Hospital Affiliations / Click here to enter text. /
Name of Supervising Physician / Click here to enter text. / Specialty / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / Telephone No. / Click here to enter text. /
Hospital Affiliations / Click here to enter text. /
Name of Supervising Physician / Click here to enter text. / Specialty / Click here to enter text. /
Address / Click here to enter text. / Suite / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. / Telephone No. / Click here to enter text. /
Hospital Affiliations / Click here to enter text. /

List all Medical Schools/Institutions attended including undergraduate and graduate schools for allied health practitioners. Enclose copies of your diplomas and certificates.

Medical Professional School / Click here to enter text. /
Degree Awarded / Click here to enter text. / Date of Graduation / MM/YY /
Address / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. /
Medical Professional School / Click here to enter text. /
Degree Awarded / Click here to enter text. / Date of Graduation / Click here to enter text. /
Address / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. /
V. POST GRADUATE TRAINING
INTERNSHIP / Program successfully completed? / ☐Yes ☐No
Internship Institution/Hospital / Click here to enter text. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Address / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. /
Internship Phone No. / xxx-xxx-xxxx / Residency Fax No. / xxx-xxx-xxxx /
RESIDENCY / Program successfully completed? / ☐Yes ☐No
Residency Institution/Hospital / Click here to enter text. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Address / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. /
Residency Phone No. / xxx-xxx-xxxx / Residency Fax No. / xxx-xxx-xxxx /
FELLOWSHIP / Program successfully completed? / ☐Yes ☐No
Institution/Hospital / Click here to enter text. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Address / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. /
Phone No. / xxx-xxx-xxxx / Fax No. / xxx-xxx-xxxx /
OTHER INSTITUTION / Program successfully completed? / ☐Yes ☐No
Institution/Hospital / Click here to enter text. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Address / Click here to enter text. /
City / Click here to enter text. / State / Click here to choose a state
Click here to indicate “other”
Zip / Click here to enter text. /
Phone No. / xxx-xxx-xxxx / Fax No. / xxx-xxx-xxxx /

Directions for sections VI & VII: List in chronological order (with the current affiliation first) all institutions where you have current affiliations and have had previous hospital privileges. This includes hospitals, residential treatment and rehabilitation centers, surgery centers, institutions, corporations, military assignments, or government agencies. Work history should include self-employment. If more space is needed, attach additional sheet(s). A CurriculumVitae (CV) is not sufficient as replacement for these sections.

VI. HOSPITAL/FACILITY HISTORY
Current Primary Admitting Facility / Click here to enter text. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Address / Click here to enter text. /
Suite / Click here to enter text. / City / Click here to enter text. /
State / Click here to choose a state
Click here to indicate “other” / Zip / Click here to enter text. /
Department / Click here to enter text. / Specialty / Click here to enter text. /
Phone No. / xxx-xxx-xxxx / Fax No. / xxx-xxx-xxxx /
Staff Category / Click here to enter text. / Chairperson / Click here to enter text. /
Admitting Facility / Click here to enter text. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Address / Click here to enter text. /
Suite / Click here to enter text. / City / Click here to enter text. /
State / Click here to choose a state
Click here to indicate “other” / Zip / Click here to enter text. /
Department / Click here to enter text. / Specialty / Click here to enter text. /
Phone No. / xxx-xxx-xxxx / Fax No. / xxx-xxx-xxxx /
Staff Category / Click here to enter text. / Chairperson / Click here to enter text. /
Admitting Facility / Click here to enter text. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Address / Click here to enter text. /
Suite / Click here to enter text. / City / Click here to enter text. /
State / Click here to choose a state
Click here to indicate “other” / Zip / Click here to enter text. /
Department / Click here to enter text. / Specialty / Click here to enter text. /
Phone No. / xxx-xxx-xxxx / Fax No. / xxx-xxx-xxxx /
Staff Category / Click here to enter text. / Chairperson / Click here to enter text. /
Admitting Facility / Click here to enter text. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Address / Click here to enter text. /
Suite / Click here to enter text. / City / Click here to enter text. /
State / Click here to choose a state
Click here to indicate “other” / Zip / Click here to enter text. /
Department / Click here to enter text. / Specialty / Click here to enter text. /
Phone No. / xxx-xxx-xxxx / Fax No. / xxx-xxx-xxxx /
Staff Category / Click here to enter text. / Chairperson / Click here to enter text. /
VII. WORK HISTORY (Add additional sheets if more space required.)
Chronologically list all medical work history.Explain any gaps of more than thirty days.
Current Practice / Click here to enter text. /
Contact Name / Click here to enter text. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Address / Click here to enter text. /
Suite / Click here to enter text. / City / Click here to enter text. /
State / Click here to choose a state
Click here to indicate “other” / Zip / Click here to enter text. /
Phone No. / xxx-xxx-xxxx / Fax No. / xxx-xxx-xxxx /
Professional Practice / Click here to enter text. /
Contact Name / Click here to enter text. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Address / Click here to enter text. /
Suite / Click here to enter text. / City / Click here to enter text. /
State / Click here to choose a state
Click here to indicate “other” / Zip / Click here to enter text. /
Phone No. / xxx-xxx-xxxx / Fax No. / xxx-xxx-xxxx /
Professional Practice / Click here to enter text. /
Contact Name / Click here to enter text. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Address / Click here to enter text. /
Suite / Click here to enter text. / City / Click here to enter text. /
State / Click here to choose a state
Click here to indicate “other” / Zip / Click here to enter text. /
Phone No. / xxx-xxx-xxxx / Fax No. / xxx-xxx-xxxx /
Professional Practice / Click here to enter text. /
Contact Name / Click here to enter text. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Address / Click here to enter text. /
Suite / Click here to enter text. / City / Click here to enter text. /
State / Click here to choose a state
Click here to indicate “other” / Zip / Click here to enter text. /
Phone No. / xxx-xxx-xxxx / Fax No. / xxx-xxx-xxxx /
Professional Practice / Click here to enter text. /
Contact Name / Click here to enter text. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Address / Click here to enter text. /
Suite / Click here to enter text. / City / Click here to enter text. /
State / Click here to choose a state
Click here to indicate “other” / Zip / Click here to enter text. /
Phone No. / xxx-xxx-xxxx / Fax No. / xxx-xxx-xxxx /
Professional Practice / Click here to enter text. /
Contact Name / Click here to enter text. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Address / Click here to enter text. /
Suite / Click here to enter text. / City / Click here to enter text. /
State / Click here to choose a state
Click here to indicate “other” / Zip / Click here to enter text. /
Phone No. / xxx-xxx-xxxx / Fax No. / xxx-xxx-xxxx /
VIII. TIME INTERVALS (Explain any time intervals not accounted for in application.)
Suspended from Practice / Click here to provide explanation. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Loss of License / Click here to provide explanation. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Served in Military / Click here to provide explanation. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Personal Leave / Click here to provide explanation /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
Other (Please describe) / Click here to provide explanation. /
Dates From / Click here to enter a date. / Dates To / Click here to enter a date. /
IX. MEDICAL PROFESSIONAL LICENSURE
Michigan State Medical/Professional License No. / Click here to enter text. /
Dates First Issued / Click here to enter a date. / Medical/Professional Expiration Date / Click here to enter a date. /
Michigan State Controlled Substance No. / Please click here to enter number /
Controlled Substance Expiration Date / Click here to enter a date. /
Drug Enforcement Administration No.
DEA Expiration Date / Click here to enter a date. /

ALL OTHER STATE MEDICAL/PROFESSIONAL LICENSES