Complete a Pre-Application

First Name:

Middle Name:

Last Name:

Address:

City:

State:

Zip Code:

Phone Number:

E-mail Address:

Social Security Number:

Date of Birth*

Country of Citizenship:

Current VISA Status:

If the answer to any question below is Yes, please provide a full explanation in the additional comments section. Have you ever been allowed to resign your employment, medical staff appointment, and/or any clinical privileges, rather than face any charge or investigation?

Yes

Have you ever been excluded from providing services in any federal health insurance program (i.e. Medicare, Medicaid, etc.)?

Yes

Do you have any medical malpractice liability suits or claims pending?

Yes

Have you ever been convicted of a felony or crime of moral turpitude?

Yes

Has any hospital ever denied, restricted, suspended, or revoked your privileges; have you ever voluntarily surrendered your privileges; or has probation ever been invoked?

Yes

Has your a narcotic or medical license ever been suspended, restricted, revoked, or voluntarily surrendered, or has probation ever been invoked?

Yes

Have you ever been evaluated or recommended for treatment for, diagnosed with, or treated for alcohol, narcotics or any other substance abuse, sexual addiction or mental health?

Yes

Have you ever been asked to participate in or have you volunteered to participate in an impaired physician program? (If Yes, please E-mail us a copy of your recovery plan):

Yes

If Yes to the question above, what was your participation?

Mandatory

n/a

Voluntary

Have you ever been denied a medical license or been denied certification by a specialty board?

Yes

Have you ever had any claims of sexual misconduct made against you?

Yes

Have you ever had your request for malpractice coverage denied, your policy canceled or non-renewed or had a policy issued to you that contained restrictions or special exclusion?

Yes

Has a patient or his representative ever filed a complaint or grievance against you with a hospital/committee, state licensing or regulatory agency or other medical review committee?

Yes

Other than a minor traffic offense, have you ever been convicted of or pled guilty to or entered into a plea agreement for a violation of any law or ordinance?

Yes

In the past twelve months, have you had any injury, illness, or other event occur that may impair, lessen or diminish your physical or mental ability to practice medicine?

Yes

Have you ever appeared before, been investigated by, or entered into any consent agreement with any formal hospital committee, state licensing Board, Board of Medical Examiners, or other medical review committee?:

Yes

Have any claims or suits ever been made or brought against you?

Yes

Indicate number of previous claims or suits (include closed, dismissed, and/or dropped cases):

Indicate number of pending claims or suits:

Do you have any knowledge of any claims which might be made against you (other than those indicated above) or activities that might reasonably give rise to a claim or suit being brought against you even if you believe the claim or suit would be without merit? (Include any requests for medical records.):

Yes

Additional Comments:

Give the names of three professional references not related to you, whom you have known for at least 12 months.

Reference #1 Name:

Reference #1 Title:

Reference #1 Phone:

Reference #2 Name:

Reference #2 Title:

Reference #2 Phone:

Reference #3 Name:

Reference #3 Title:

Reference #3 Phone:

By clicking Submit , I certify that the above information, the information provided on my Curriculum Vitae are complete and truthful as of this date, and I will request a self-query from the National Practitioner Data Bank and direct it to: Davis Health System, Attn: Lori Burnside, Medical Staff Liaison, P.O. Box 1484, Elkins, WV 26241. The Data Bank can be contacted via the Internet at: www.npdb-hipdb.com or NPDB Customer Service at: 1-800-767-6732. By clicking Submit it also authorizes the Davis Health System Physician Recruitment Staff or its Physician Leadership to contact as applicable my Residency and/or Fellowship Training Director and/or the following Professional References: Residency and/or Fellowship Training Director with Contact Information:

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Complete a Pre-Application