Pre-Application Providers Form

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


Residency/Other Training

Board Certification


DEA Registration

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 Or have you voluntarily relinquished, withdrawn, or failed to proceed with an application for any of the following in order to avoid an adverse action or to preclude an investigation or while under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?

Criminal History

Affirmation of Abilities

Litigation and Malpractice Coverage History

Adverse Actions

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.

Click or drag files to this area to upload. You can upload up to 3 files.
Clear Signature
Applicant's Signature