Healthcare Qualifications Form

HEALTHCARE QUALIFICATIONS FORM

Applicant Information

Applicant Name:

Professional Designation:    Date of Birth:

Licensure and Certifications

Primary State License Number:    Issuing State:    Expiration:

National Provider Identifier (NPI):    DEA Number (if applicable):

Education and Training

Graduation Year:    Residency:

Board Certification

Board Certified: Yes    Certifying Board:    Year:

Practice and Employment History (Past 5 Years)

Provide principal practice and previous employers. Attach additional pages if necessary.

Position/Title:    From:    To:

Position:    From:    To:

Position:    From:    To:

Privileges, Malpractice and Claims History

Policy Limits:

Have you ever been named in a malpractice claim or suit? Yes No

Disciplinary, Legal and Criminal History

Has any licensing board, professional society, employer, or governmental agency taken adverse action against you? Yes No

Have you ever been convicted of a felony or pleaded guilty/no contest to a felony? Yes No

Health Status and Immunizations

Are you currently able to perform the essential functions of your clinical role with or without accommodation? Yes No

Professional References

Privacy Acknowledgment and Authorization

I acknowledge receipt of the organization's privacy practices and understand that the information provided on this form will be used to verify my credentials, determine privileges or employment eligibility, and for related administrative purposes.

Authorization: I hereby authorize any individual, institution, agency, licensing board, malpractice carrier, employer, educational institution, law enforcement agency, and other third parties to release to the organization any information, records or documents necessary to verify the information I have provided. I understand that this authorization includes release of information concerning licensure, professional conduct, malpractice claims, criminal history, employment history, and other matters relevant to assessment of my qualifications.

This authorization remains in effect until:

I understand that falsification, omission, or misrepresentation of information on this form may be grounds for denial, discipline, or termination of privileges or employment, and may be reported to licensing authorities or other entities as appropriate.

HIPAA Privacy Acknowledgment: I acknowledge that I have been provided with or offered the applicable privacy practices relating to protected health information. I acknowledge.

Certification and Signature

Certification: I certify under penalty of perjury that the information provided in this Healthcare Qualifications Form is complete and true to the best of my knowledge. I understand that the organization may rely on this information in evaluating my qualifications and that supplementary documentation may be requested.

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