Locums Application - Foster Crown

I. APPLICANT INFORMATION.

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II. APPLICANT EDUCATION & TRAINING.

THIS SECTION CAN BE LEFT BLANK IF APPLICANT HAS INCLUDED A CURRICULUM VITAE (CV) WITH COMPLETE EDUCATION AND TRAINING INFORMATION.

<h3><span style="color: #001689;"><em>THIS SECTION CAN BE LEFT BLANK IF APPLICANT HAS INCLUDED A CURRICULUM VITAE (CV) WITH COMPLETE EDUCATION AND TRAINING INFORMATION.</em></span></h3>

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1. Schools.

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2. Internships.

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Do you have additional internships to list?

YesNo

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Do you have additional internships to list?

YesNo

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3. Residencies

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Do you have additional residencies to list?

YesNo

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Do you have additional residencies to list?

YesNo

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4. Fellowships.

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Do you have additional fellowships to list?

YesNo

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Do you have additional fellowships to list?

YesNo

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List all states in which you have held a license to practice medicine and your current licensure status.

<h3><span style="color: #001689;"><em>List all states in which you have held a license to practice medicine and your current licensure status.</em></span></h3>

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Board Certification

a) List names of specialty boards by which you are certified:

<h4><strong>a)</strong> List names of specialty boards by which you are certified:</h4><br />
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b) If not certified, have you applied for certification examination?

<h4><strong>b)</strong> If not certified, have you applied for certification examination?</h4><br />
<br>

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YesNo

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Indicate which boards and the dates you are scheduled to take the certification examination:

<h4>Indicate which boards and the dates you are scheduled to take the certification examination:</h4>

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III. PROFESSIONAL LIABILITY INFORMATION.

1. Have any disciplinary actions been initiated or are any pending against you by any state licensure board?

1. Have any disciplinary actions been initiated or are any pending against you by any state licensure board?<br><br>

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Yes

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2. Has your license to practice medicine in any state ever been denied, limited, suspended, or revoked?

2. Has your license to practice medicine in any state ever been denied, limited, suspended, or revoked?<br><br>

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Yes

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3. Have you ever been suspended, sanctioned or otherwise restricted from participating in any private, federal, or state health insurance program (for example: Medicare, Medicaid)?

3. Have you ever been suspended, sanctioned or otherwise restricted from participating in any private, federal, or state health insurance program (for example: Medicare, Medicaid)?<br><br>

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Yes

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4. Has your controlled substance registration ever been limited, suspended or revoked?

4. Has your controlled substance registration ever been limited, suspended or revoked?<br><br>

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Yes

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5. Has your professional liability insurance coverage ever been terminated by action of the insurance company?

5. Has your professional liability insurance coverage ever been terminated by action of the insurance company?<br><br>

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Yes

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6. Have you ever been denied professional liability insurance coverage?

6. Have you ever been denied professional liability insurance coverage?<br><br>

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Yes

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7. Have any professional liability suits ever been filed against you, including suits which were subsequently dropped?

7. Have any professional liability suits ever been filed against you, including suits which were subsequently dropped?<br><br>

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Yes

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8. Have any professional liability suits been filed against you, which are presently pending?

8. Have any professional liability suits been filed against you, which are presently pending?<br><br>

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Yes

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9. Have any judgements or settlements been made against you in professional liability cases?

9. Have any judgements or settlements been made against you in professional liability cases?<br><br>

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Yes

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10. Have you ever been the subject of any administrative, civil, or criminal complaint or investigation regarding sexual misconduct?

10. Have you ever been the subject of any administrative, civil, or criminal complaint or investigation regarding sexual misconduct?<br><br>

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Yes

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11. Have any of your medical staff appointments or clinical privileges ever been suspended, diminished, revoked, refused or limited at any hospital or other healthcare facility?

11. Have any of your medical staff appointments or clinical privileges ever been suspended, diminished, revoked, refused or limited at any hospital or other healthcare facility?<br><br>

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Yes

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12. Have you ever been convicted of a crime (other than a minor traffic offense) or are you currently under indictment for an alleged crime?

12. Have you ever been convicted of a crime (other than a minor traffic offense) or are you currently under indictment for an alleged crime?<br><br>

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Yes

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ADDITIONAL INFORMATION:

If you answered "yes" to any of the above questions, provide a full explanation below:

<h3><span style="color: #001689;"><em>If you answered "yes" to any of the above questions, provide a full explanation below:</em></span></h3>

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Do you have supplemental claim information?

YesNo

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APPLICANT SIGNATURE

I understand information submitted herein becomes a part of my professional liability application and is subject to the same warranty and conditions.

<h3><span style="color: #001689;"><em>I understand information submitted herein becomes a part of my professional liability application and is subject to the same warranty and conditions.</em></span></h3>

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REFERENCES

Please list 3 professional references, not including relatives, who have had the opportunity to work closely with you within the last 2 years. Please provide current and complete addresses and phone numbers. These individuals will be contacted and asked to complete a reference over the phone.

<h3><span style="color: #001689;"><em>Please list 3 professional references, not including relatives, who have had the opportunity to work closely with you within the last 2 years. Please provide current and complete addresses and phone numbers. These individuals will be contacted and asked to complete a reference over the phone.</em></span></h3>

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Reference 1.

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Reference 2.

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Reference 3.

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RELEASE & AUTHORIZATION

In making an application to Foster Crown, LLC (FC), I certify that the information I have provided to FC is true and accurate and that it may be used by FC for evaluating my potential as a Locum Tenens Physician, and that FC will rely on the truthfulness of my application.

With regard to this application, I authroize Foster Crown, LLC and its representatives to obtain any information that may be relevant to an evaluation of my professional qualifications, including information and disciplinary actions or other credentials or confidential information.

I hereby release from liability Foster Crown, LLC, its officers, employees, and representatives, and third parties who provide or receive information regarding my credentials in good faith and without malice. Further, I agree to indemnify, defend and hold Foster Crown, LLC harmless, from any and all claims, causes or action, damages, judgements and expenses, arising from or related to the collection, verification and dissemination of my credentialing information.

I understand that I have the burden of providing accurate information to Foster Crown, LLC to demonstrate my qualifications and that any misrepresentation on this application may constitute grounds for canceling my assignments and malpractice policy.

I understand that I am responsible for notifying Foster Crown, LLC of any changes affecting my professional status.

I understand that the decision to refer me to Foster Crown, LLC clients is at the discretion of Foster Crown, LLC.

I understand the information provided by references is confidentialand will not be released to me without the consent of the reference.

<h3>In making an application to Foster Crown, LLC (FC), I certify that the information I have provided to FC is true and accurate and that it may be used by FC for evaluating my potential as a Locum Tenens Physician, and that FC will rely on the truthfulness of my application. 
 
With regard to this application, I authroize Foster Crown, LLC and its representatives to obtain any information that may be relevant to an evaluation of my professional qualifications, including information and disciplinary actions or other credentials or confidential information. 
 
I hereby release from liability Foster Crown, LLC, its officers, employees, and representatives, and third parties who provide or receive information regarding my credentials in good faith and without malice. Further, I agree to indemnify, defend and hold Foster Crown, LLC harmless, from any and all claims, causes or action, damages, judgements and expenses, arising from or related to the collection, verification and dissemination of my credentialing information. 
 
I understand that I have the burden of providing accurate information to Foster Crown, LLC to demonstrate my qualifications and that any misrepresentation on this application may constitute grounds for canceling my assignments and malpractice policy. 
 
I understand that I am responsible for notifying Foster Crown, LLC of any changes affecting my professional status. 
 
I understand that the decision to refer me to Foster Crown, LLC clients is at the discretion of Foster Crown, LLC. 
 
I understand the information provided by references is confidentialand will not be released to me without the consent of the reference.</h3>

<h3><span style="color: #001689;"><em>In making an application to Foster Crown, LLC (FC), I certify that the information I have provided to FC is true and accurate and that it may be used by FC for evaluating my potential as a Locum Tenens Physician, and that FC will rely on the truthfulness of my application.<br />
<br />
With regard to this application, I authroize Foster Crown, LLC and its representatives to obtain any information that may be relevant to an evaluation of my professional qualifications, including information and disciplinary actions or other credentials or confidential information.<br />
<br />
I hereby release from liability Foster Crown, LLC, its officers, employees, and representatives, and third parties who provide or receive information regarding my credentials in good faith and without malice. Further, I agree to indemnify, defend and hold Foster Crown, LLC harmless, from any and all claims, causes or action, damages, judgements and expenses, arising from or related to the collection, verification and dissemination of my credentialing information.<br />
<br />
I understand that I have the burden of providing accurate information to Foster Crown, LLC to demonstrate my qualifications and that any misrepresentation on this application may constitute grounds for canceling my assignments and malpractice policy.<br />
<br />
I understand that I am responsible for notifying Foster Crown, LLC of any changes affecting my professional status.<br />
<br />
I understand that the decision to refer me to Foster Crown, LLC clients is at the discretion of Foster Crown, LLC.<br />
<br />
I understand the information provided by references is confidentialand will not be released to me without the consent of the reference.</em></span></h3>

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SUBMIT

I. APPLICANT INFORMATION.

II. APPLICANT EDUCATION & TRAINING.

THIS SECTION CAN BE LEFT BLANK IF APPLICANT HAS INCLUDED A CURRICULUM VITAE (CV) WITH COMPLETE EDUCATION AND TRAINING INFORMATION.

1. Schools.

2. Internships.

3. Residencies

4. Fellowships.

List all states in which you have held a license to practice medicine and your current licensure status.

Board Certification

a) List names of specialty boards by which you are certified:

b) If not certified, have you applied for certification examination?

Indicate which boards and the dates you are scheduled to take the certification examination:

III. PROFESSIONAL LIABILITY INFORMATION.

ADDITIONAL INFORMATION:

If you answered "yes" to any of the above questions, provide a full explanation below:

SUPPLEMENTAL CLAIM INFORMATION

Answer All Questions Completely

Disposition of Claim

Indicate Judgement Type

Disposition of Claim

SUPPLEMENTAL CLAIM INFORMATION

Answer All Questions Completely

Disposition of Claim

Indicate Judgement Type

Disposition of Claim

SUPPLEMENTAL CLAIM INFORMATION

Answer All Questions Completely

Disposition of Claim

Indicate Judgement Type

Disposition of Claim

APPLICANT SIGNATURE

I understand information submitted herein becomes a part of my professional liability application and is subject to the same warranty and conditions.

REFERENCES

Please list 3 professional references, not including relatives, who have had the opportunity to work closely with you within the last 2 years. Please provide current and complete addresses and phone numbers. These individuals will be contacted and asked to complete a reference over the phone.

Reference 1.

Reference 2.

Reference 3.

RELEASE & AUTHORIZATION