Clinical Privilege Employment Application

Clinical Privilege Employment Application

Personal Information

Date of Birth:   Gender:

Primary Phone:   Secondary Phone:

Position Information

Department:   Reporting Manager:

Desired Start Date:   Employment Type: Full-Time Part-Time PRN/Per Diem

Clinical Credentials and Licensing

Professional License Number:   Issuing State:

License Issue Date:   License Expiration Date:

DEA Number:   NPI Number:

Malpractice Insurance and Claims History

Malpractice Insurance Carrier:   Policy Number:

Have you ever had a malpractice claim, settlement, judgment, or pending action? No Yes — if yes, provide details below

Employment History (Most Recent First)

Title / Position:   Start Date:   End Date:

Title / Position:   Start Date:   End Date:

Education

Graduation Date:   Other Relevant Training / Fellowships:

Professional References

Phone:   Email:   Relationship:

Phone:   Email:   Relationship:

Phone:   Email:   Relationship:

Health, Background, and Regulatory Disclosures

Are you currently subject to investigation, limitation, suspension, revocation, or any disciplinary action by any licensing board, hospital, or professional organization? No Yes

Have you ever been convicted of a felony or misdemeanor related to professional practice or patient care? No Yes

Required Immunizations and Screening: I affirm that I have met the organization's immunization, TB screening, and health clearance requirements as applicable. Yes No

Authorization, Releases and Certifications

I certify that the information provided in this application is true, complete, and correct to the best of my knowledge. I understand that any misrepresentation, omission, or falsification may result in denial of privileges or termination of employment/appointment.

I authorize the facility and its agents to verify any information contained herein, to contact references, current and prior employers, licensing authorities, and insurance carriers, and to obtain criminal background checks, professional liability history, and other credentialing information as necessary for privileging and employment decisions.

I further authorize the release of peer review, credentialing, and adverse action information by hospitals and other credentialing entities to the facility for the purpose of evaluating my application for clinical privileges. I release such entities from liability for providing such information in good faith.

I understand that privileges granted are subject to periodic review, oversight, and conditions of practice established by the facility. Granting of privileges does not create a property right in continued privileges and may be modified or revoked in accordance with facility policy.

Equal Opportunity Statement: The facility provides equal employment and appointment opportunities without regard to race, color, religion, sex, national origin, age, disability, or any other protected characteristic.

I authorize the release of information and consent to the background and credential checks described above.

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