Pre-Application Providers Form - Community Health of Central Washington

The information contained on this application will be used to query the National Practitioner Data Bank, perform state patrol criminal background checks, check state licenses, verify education and training, etc. By completing this form, you authorize Community Health of Central Washington to perform these verifications.

Personal Information

Name: *

First

Last

Specialty: *

Other Name(s) Used:

Clinic Applying At: *

For other, please specify: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth: *

Social Security #: *

Are you legally able to work for any employer in the U.S.? *

Yes
No

If no, please explain: *

If you are working under a VISA, are there any restrictions?

Yes
No

If yes, please explain: *

How Did You Hear About This Opening?

Education

Name of Professional School: *

Location of Professional School (City, State): *

Date Graduated: *

Degree: *

Completed: *

Yes
No

Residency/Other Training

Name of Residency Training Program: *

Location of Residency Program (City, State): *

Date Graduated: *

Specialty: *

Completed: *

Yes
No

Name of Other Post-Graduate Training Program:

Location of Program (City, State):

Date Graduated:

Degree/Specialty:

Completed:

Yes
No

Board Certification

Board Certified? *

Yes
No

Board Eligible? *

Yes
No

Name of Board:

Board Date:

Board Expiration Date:

Licenses

License Number:

State:

License Expiration Date:

License Number:

State:

License Expiration Date:

License Number:

State:

License Expiration Date:

DEA Registration

DEA Registration Number:

DEA Expiration Date:

Please answer all of the following questions. If your answer to any of the following questions is “yes"; please provide details in the space below or on a separate sheet. If you attach additional sheets, please sign and date each sheet.

Professional Sanctions

1. Have you ever been, or are you now in the process of being denied, revoked, terminated, suspended, restricted, reduced, limited, sanctioned, placed on probation, monitored, or not renewed for any of the following? Or have you voluntarily relinquished, withdrawn, or failed to proceed with an application for any of the following in order to avoid an adverse action or to preclude an investigation or while under investigation relating to professional competence or conduct?

a. License to practice any profession in any jurisdiction *

Yes
No

b. Other professional registration or certification in any jurisdiction *

Yes
No

c. Specialty or subspecialty board certification *

Yes
No

d. Membership on any hospital medical staff *

Yes
No

e. Clinical privileges at any facility, including hospitals, ambulatory surgical centers, skilled nursing facilities, etc. *

Yes
No

f. Medicare, Medicaid, FDA, NIH (Office of Human Research Protection), governmental, national or international regulatory agency or any public program *

Yes
No

g. Professional society membership or fellowship *

Yes
No

h. Participation/membership in an HMO, PPO, IPA, PHO or other entity *

Yes
No

i. Academic Appointment *

Yes
No

j. Authority to prescribe controlled substances (DEA or other authority) *

Yes
No

2. Have you ever been subject to review and/or disciplinary action, formal or informal, by an ethics committee, licensing board, medical disciplinary board, professional association or education/training institution? *

Yes
No

3. Have you been found by a state professional disciplinary board to have committed unprofessional conduct as defined in applicable state provisions? *

Yes
No

4. Have you ever been the subject of any reports to a state, federal, national data bank, or state licensing or disciplinary entity? *

Yes
No

Criminal History

1. Have you ever been charged with a criminal violation (felony or misdemeanor) resulting in either a plea bargain, conviction on the original or lesser charge, or payment of a fine, suspended sentence, community service or other obligation? *

Yes
No

a. Do you have notice of any such anticipated charges? *

Yes
No

b. Are you currently under governmental investigation? *

Yes
No

Affirmation of Abilities

1. Do you presently use any drugs illegally? *

Yes
No

2. Do you have, or have you had in the last two years, any physical condition, mental health condition, or chemical dependency condition (alcohol or other substance) that affects or will affect your current ability to practice with or without reasonable accommodation? *

Yes
No

If reasonable accommodation is required, specify the accommodations required.

If the answer to this question is yes, please identify and describe any rehabilitation program in which you are or were enrolled which assures your ability to adhere to prevailing standards of professional performance. *

3. Are you unable to perform any of the services/clinical privileges required by the applicable participating practitioner agreement/hospital agreement, with or without reasonable accommodation, according to accepted standards of professional performance? *

Yes
No

Litigation and Malpractice Coverage History

1. Have allegations or claims of professional negligence been made against you at any time, whether or not you were individually named in the claim or lawsuit? *

Yes
No

2. Have you or your insurance carrier(s) ever paid any money on your behalf to settle/resolve a professional malpractice claim (not necessarily a lawsuit) and/or to satisfy a judgment (court-ordered damage award) in a professional lawsuit? *

Yes
No

3. Are there any such claims being asserted against you now? *

Yes
No

4. Have you ever been denied professional liability coverage or has your coverage ever been terminated, not renewed, restricted, or modified (e.g. reduced limits, restricted coverage, surcharged)? *

Yes
No

5. Are any of the privileges that you are requesting not covered by your current malpractice coverage? *

Yes
No

Adverse Actions

Please explain any adverse license sanctions, malpractice events, clinical privilege denials, criminal history or any type of investigation or discipline related to your practice below:

If you need to attach any documents for any "yes" answers above.

Click or drag files to this area to upload. You can upload up to 5 files.

Peer References

List three professional references, from your specialty area, not including relatives, who have worked with you in the past two years. References must be from individuals who through recent observation, are directly familiar with your work and can attest to your clinical competence in your specialty area. If you have been out of residency for a period of less than three years, one reference must be from the Program Director.

Name of Reference: *

First

Last

Title and Specialty: *

Email: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Telephone Number: *

Fax Number:

Cell Number:

Name of Reference: *

First

Last

Title and Specialty: *

Email: *

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Telephone Number: *

Fax Number:

Cell Number:

Name of Reference: *

First

Last

Title and Specialty: *

Email: *

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Telephone Number: *

Fax Number:

Cell Number:

Please upload your Curriculum Vitae and Letter of Interest. If there are any issues with uploading please email documents to Michelle.Mears@chcw.org *

Click or drag files to this area to upload. You can upload up to 3 files.

I warrant that all the statements made on this form and on any attached information sheets are true and correct. I understand that any material misstatements in, or omissions from, this statement constitute cause for denial of membership or cause for summary dismissal from the entity to which this statement has been submitted. *

Clear Signature

Applicant's Signature

Date: *