6451 Brentwood Stair Road, Suite 200
Fort Worth, Texas 76112
Main (817) 496-9700
Toll Free (800) 569-0938
Fax (817) 507-1775
www.emdocs.com
Advance Practice Clinician Application
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PERSONAL INFORMATION
PA ______
Full Name ______NP ______
Last First Middle Other ______
Other names use d and dates of use ______
Home Address______
Street City State Zip Code
Office Address______
Street City State Zip Code
Home Phone ______Home Fax ______Mobile ______
Work Phone ______Work Fax ______
Home Email Work Email
Marital Status □ Single □ Married Spouse
Date of Birth ______Social Security # ______Citizenship
Place of Birth: ______County ______Country
Driver’s License # ______State ______Expiration Date
NPI # ______
Emergency Contact:
Name ______Relationship ______Phone Number ______
EDUCATION
High SchoolName
AddressFrom (mm/dd/yyyy) / To (mm/dd/yyyy) / Graduation Date (mm/dd/yyyy)
College or University
Name
Address / DegreeFrom (mm/dd/yyyy) / To (mm/dd/yyyy) / Graduation Date (mm/dd/yyyy)
Post-Graduate Education / Director of Program / From (mm/dd/yyyy) / To (mm/dd/yyyy)
Name
Address / DegreeTraining other than College or University / Director of Program / From
(mm/dd/yyyy) / To (mm/dd/yyyy)
Name
AddressCourse of Study
MILITARY EXPERIENCE
Branch / Dates
Present Status / Date of Discharge
LICENSURE/CERTIFICATION
Medical License (TMB) / LicenseNumber / Issue Date
(mm/dd/yyyy) / Expiration Date
(mm/dd/yyyy) / State
1.
2.
NCCPA/AANP / License
Number / Issue Date
(mm/dd/yyyy) / Expiration Date
(mm/dd/yyyy) / State
1.
DEA Registration Number /
State
/Expiration Date
(mm/dd/yyyy)1. / /
2. / /
State Controlled Substance Registration-
DPS Number / State / Expiration Date
(mm/dd/yyyy)
1.
2.
OTHER CERTIFICATION
BLS □ Yes □ No / Expires______/ ACLS □ Yes □ No / Expires______
SPECIALTY INFORMATION
Certified:
□ Yes □ No / Name of Board / Certification Date / Expiration Year
Certified:
□ Yes □ No / Name of Board / Certification Date / Expiration Year
List all malpractice insurance carriers for the past five years. If insurance is through a group, please name group.
INSURANCE INFORMATION/LEGAL ACTIONS
Present Carrier
/ Policy NumberAddress City State Zip Code
Type of Policy:
□ Occurrence
□ Claims-Made / Group Name / Effective Date
(mm/dd/yy) / Expiration Date
(mm/dd/yy) / Claim Limit / Aggregate Limit
Present Carrier
/ Policy NumberAddress City State Zip Code
Type of Policy:
□ Occurrence
□ Claims-Made / Group Name / Effective Date
(mm/dd/yy) / Expiration Date
(mm/dd/yy) / Claim Limit / Aggregate Limit
Previous Carrier
/ Policy NumberAddress City State Zip Code
Type of Policy:
□ Occurrence
□ Claims-Made / Group Name / Effective Date
(mm/dd/yy) / Expiration Date
(mm/dd/yy) / Claim Limit / Aggregate Limit
Previous Carrier
/ Policy NumberAddress City State Zip Code
Type of Policy:
□ Occurrence
□ Claims-Made / Group Name / Effective Date
(mm/dd/yy) / Expiration Date
(mm/dd/yy) / Claim Limit / Aggregate Limit
REFERENCES
Please provide at least three (3) members of your same discipline and two (2) physician references who can attest to your clinical competence and work ethics. Please note: Complete names, addresses, and e-mail addresses are required to ensure faster completion of your application.Name Specialty/Title
Facility E-mail
Address
City/State Zip Code
Home Phone Work Phone Fax Number
Name Specialty/Title
Facility E-mail
Address
City/State Zip Code
Home Phone Work Phone Fax Number
Name Specialty/Title
Facility E-mail
Address
City/State Zip Code
Home Phone Work Phone Fax Number
Please list your physician reference:
Name Specialty/Title
Facility E-mail
Address
City/State Zip Code
Home Phone Work Phone Fax Number
Please list your current Emergency Department Medical Director:
Name Specialty/Title
Facility E-mail
Address
City/State Zip Code
Home Phone Work Phone Fax Number
PRACTICE AFFILIATIONS – List all hospitals, employers and contract groups. Include all time periods since completion of training with most recent first. List additional facilities on separate page.
HOSPITAL/EMPLOYER/CONTRACT GROUP
/ PT/FT / EDVol./Yr. / Dates
Mo/Yr-Mo/Yr / Staff Status / Dept.*
1. Facility
Address / City, State, Zip
2. Facility
Address / City, State, Zip
3. Facility
Address / City, State, Zip
4. Facility
Address / City, State, Zip
5. Facility
Address / City, State, Zip
6. Facility
Address / City, State, Zip
7. Facility
Address / City, State, Zip
8. Facility
Address / City, State, Zip
9. Facility
Address / City, State, Zip
*FP - Family Practice, EM - Emergency Medicine; IM – Internal Medicine, etc.
* If you answer is “yes” to any of the following questions, give full details on a separate attachment
PROFESSIONAL LICENSE
□ Yes □ No 1. Have any of your health care licenses ever been voluntarily or involuntarily suspended, limited, revoked, or non-renewed?
□ Yes □ No 2. Have you ever withdrawn a license application?
□ Yes □ No 3. Have you ever been denied a health care license to practice?
□ Yes □ No 4. Has your DEA or DPS ever been voluntarily or involuntarily suspended, revoked, or non- renewed? □ N/A
APPOINTMENTS / CLINICAL PRIVILEGES / MEMBERSHIPS
□ Yes □ No 4. Have you ever been refused admission or denied specific clinical privileges to any Allied Health Staff?
□ Yes □ No 5. Have you ever voluntarily or involuntarily withdrawn your application for appointment, clinical privileges, or reappointment at any medical facility, or resigned from an Allied Health Staff, while a disciplinary action regarding the status of your privileges was pending before any peer review or other disciplinary body of any medical facility?
□ Yes □ No 6. Have your privileges at any hospital or medical facility ever been voluntarily or involuntarily suspended, limited, or revoked?
□ Yes □ No 7. Have you ever been the subject of any disciplinary proceedings at any medical facility or organization?
□ Yes □ No 8. Has a physician or other mid-level ever been assigned by a health care facility to monitor any aspect of your practice or have you ever been subject to a mandatory, concurrent opinion requirement?
PROFESSIONAL LIABILITY
□ Yes □ No 9. Have you ever been denied professional liability insurance?
□ Yes □ No 10. Has your current or any prior professional liability insurance carrier restricted your coverage or notified you that it intends to reduce or terminate your coverage?
□ Yes □ No 11. Have any professional liability claims/suits ever been filed against you?
If yes, how many? ______□ If yes, check this box and complete Attachment A
□ Yes □ No 12. Have you ever settled any professional liability claim prior to suit being filed with or without admitting liability as a part of the settlement?
□ Yes □ No 13. Are you aware of any inquiry by an attorney representing a patient or family member about health care you provided, other than those reported to your professional liability carrier?
□ Yes □ No 14. Do you staff, invest in, or own an emergency or minor emergency care facility, laboratory, or other outpatient facility?
SANCTIONS
□ Yes □ No 15. Have you ever been excluded, sanctioned, voluntarily or involuntarily suspended, or otherwise restricted from participation in any federal, state, or private health insurance program? (i.e., Medicare, Medicaid)
HEALTH STATUS
□ Yes □ No 16. Do you have or have you ever had a physical or mental condition that could affect your ability to exercise the clinical privileges requested or to provide services? If yes, would an accommodation presently be required in order for you to exercise the privileges requested or to provide services safely and competently or to perform the essential functions of the position? □ Yes □ No
□ Yes □ No 17. Are you presently affected by any drug, chemical, alcohol, or behavioral problem, or are you actively involved in treatment for use of or dependency on any of these?
□ Yes □ No 18. Are you currently taking any medicine that could affect your clinical judgment or motor skills?
CRIMINAL HISTORY
□ Yes □ No 19. Have you ever been indicted, prosecuted for or been convicted of a felony or misdemeanor (Class A and/or B only), including but not limited to, being placed on probation or deferred adjudication?
□ Yes □ No 20. Are there any felony or misdemeanor charges (Class A and/or B only) currently pending against you?
□ Yes □ No 21. Has any claim of sexual harassment or civil rights violation ever been made against you?
Which practice location is of interest to you?
1)______
2)______
COMPLETED APPLICATIONS REQUIRE THE FOLLOWING ITEMS:
(Please indicate which items are attached)
□ Copy of current Curriculum Vitae □ Copy of DD214, if applicable
□ Recent passport size photo □ Signature on Release of Information Statement
□ Copy of College/Training Diploma □ List or copies of CME credits for past two (2) years
□ Copy of current state license(s) □ Detailed responses to any questions answered “yes”
□ Copy of current DPS certificate, if applicable □ List of clinical rotations from your training program
□ Copy of current DEA certificate, if applicable
□ Copy of malpractice face sheet for 5 years
□ Copy of naturalization papers, green card, or visa, if applicable
□ Copy of certificates that apply to your professional credentials (NCCPA, LCCST, etc.)
□ Copy of current BLS or ACLS certificate
□ Copy of current PPD, within previous 12 months or chest x-ray narrative, if PPD positive
□ Copy of immunization records or titers: MMR, Hep B, Varicella, TDAP, Annual Flu, Annual Mask Fit (select hospitals)
Care Associates, P.A.
APPLICATION DISCLOSURE/RELEASE
Pursuant to the requirements of the Fair Credit Reporting Act, notice is given that a consumer report** may be made in connection with your application for employment.
If you are denied employment, either wholly or partly, because of information contained in a consumer report, a disclosure will be made to you of the name and address of the consumer reporting agency making such report. You will also receive a copy of the report and a statement of your consumer rights.
By signing below you consent to the procurement of a consumer report in connection with your application for employment and/or continued employment.
Applicant’s (printed) First Name: ______
Applicant’s Middle Name: ______
Applicant’s Last Name: ______
Applicant’s Other Last Names: ______
Social Security Number*: ______Date of Birth: ______
*for consumer report purposes only
Current Address
Address: ______Apt. #: ______
City: ______State: ______Zip: ______
List all cities, states and counties lived in for the last SEVEN YEARS.
(If additional space is needed, make attachment or use other side of this page)
City / State / County1.
2.
3.
4.
5.
6.
7.
** A consumer report may consist of employment records, educational verification, licensure verification, driver history, previous addresses, and other public records relative to criminal charges. A credit report will not be requested unless it is deemed pertinent to the functions of the position for which you are applying.
Applicant’s Signature: ______Date: ______
AUTHORIZATION TO RELEASE INFORMATION
I have submitted an application to become associated with CARE ASSOCIATES, PA, located at 6451 Brentwood Stair Road, #200, Fort Worth, TX 76112.
I, any and all, hereby authorize individuals, organizations, previous employers, and schools to provide any information they may have regarding me, whether or not it is in their records. This may include otherwise privileged or confidential information relative to my professional qualifications, credentials, clinical and/or professional competence, character, mental, moral behavior or, any matter having bearing on my consideration of a practice opportunity offered by or through CARE ASSOCIATES, PA.
I agree to release all individuals, organizations, previous employees, and schools from all liability for any damages, which may result from issuing this information.
Further, I extend CARE ASSOCIATES, PA, its authorized representatives, and any third parties, immunity and release from liability for information gathered from public records and/or interviews as outlined above.
Further, I authorize CARE ASSOCIATES, PA, to release the following information to any hospitals or organizations at which I am applying for medical staff privileges: (e.g., verification letters from training institutions, hospital affiliations, personal references, and insurance companies)
I hereby agree to indemnify and hold harmless CARE ASSOCIATES, PA, its owners, directors, employees, representatives, and agents, from any liability, damages, action, or cause of action resulting from the gathering or release of information outlined above.
I agree that a photocopy of this authorization is to be accepted with the same authority as the original, and I specifically waive written notice from any present or former employer and/or organization, who may provide information based upon this authorized request.
______
Name (please print)
______
Date of Birth Last 4 digits of Social Security Number
______
Maiden/former name (please print)
______
Signature Date
Attachment A
Claim/Suit Information Form
Name of Applicant ______
1. Patient/Claimant Information
Patient/Claimant Name Age Sex
2. Date(s) of treatment and/or surgery, which led to the allegations against you.
3. Nature of allegations in the claim or suit
4. Was a suit ever filed? □ Yes □ No If Yes, when
Date (MM/YY)
5. Name other doctor(s), hospital(s), or health care providers (s), if any, named in the claim or suit
6. Disposition or current status of claim or suit:
a. OPEN
Indicate case value established by carrier, if known (in $)
b. CLOSED
Was this matter closed with your consent? □ Yes □ No
Was payment made? □ Yes □ No
If No, was claim or suit withdrawn? □ Yes □ No
If Yes, indicate total amount of settlement or award $
Amount paid on your behalf $
Settlement or award date
7. Defending insurance carrier information
(Name of Insurance Carrier Defending You) Policy Number
8. Please attach a narrative description of the medical facts, which includes but not limited to the type
of treatment, and/or surgery, and your involvement.
If additional space is needed, this form may be copied.
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