Physician Medical Director Application

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Personal Data

Legal Name:

Home Phone:

Cell Phone:

Email Address:

Present Address:

City:

State:

Zip Code:

Permanent Address (if different from above):

City:

State:

Zip Code:

Please provide a current photograph (optional):

Educational History

College:

Medical School:

Internship:

Residency:

Pertinent Employment History

1. Employer:

Dates Worked:

Address:

Phone:

Supervisor’s Name and Title:

Salary/Pay (optional):

Reason for Leaving:

Positions Held and Description of Duties:

Professional Registration / License

1. Type of Registration/License/Certification:

State:

Number:

Expiration Date:

Board Certification

Board Certification:

Date Certified:

Are you eligible to take your specialty boards? Yes No

When:

Additional Information

1. Have you ever been convicted of, or do you have charges pending for any crime? (excluding minor traffic offenses) Yes No

2. Have you ever been the subject of a malpractice award or finding, or named in a malpractice suit? Yes No

3. Have your hospital or clinic staff privileges ever been limited, suspended, denied, or revoked? Yes No

4. Have you ever had your Drug Enforcement Administration Certificate or prescribing privileges limited, suspended or revoked by any state or federal agency? Yes No

5. Have you ever been convicted of Medicare or Medicaid fraud? Yes No

6. Is there any reason you may not pass the credentialing process? Yes No

7. Are you physically and mentally able to perform all the duties required of an Emergency Physician? Yes No

8. Do you have the potential to be available 24/7, 365 days per year? Yes No

9. Would you be willing to work extra night shifts? Yes No

10. Do you speak other languages? Yes No

General Questions

1. What assets would you bring to the Emergency Department?

2. What administrative experience do you have and how do you see administrative duties?

3. What will your references say about you?

4. Have you worked with Midlevel providers before? Yes No

5. Why do you think we should hire you?

6. What Personality traits make a good Emergency Department Physician and how do you fit in?

7. Why would you choose the northern Colorado area?

8. Do you have any outside interests?

Do you give us authorization for a background check? Yes No

Drivers License or State Identification Number:

Date of Birth:

Other Names you may have been known by:

References

Name:

Company Name:

Email Address:

Telephone:

Address:

City:

State:

Zip Code:

Authorization

My signature below authorizes Emergency Physicians of the Rockies, PC to obtain a background check:

Date:

I understand that I am signing this form under penalty of perjury. By signing this form, I state that the information included is true and correct to the best of my knowledge. I understand untruthful or misleading answers, or deliberate omissions are cause for denial or immediate termination of my employment contract:

Date:

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