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Provider Information

Name*

First Middle Last

Discipline

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Phone (click + to add row)

General Information

Specialty

Board Certified?*

Yes
No

Board Certifications

Medical Board	Certification Date (mm/yy)

NPI #

Date of Birth*

Place of Birth*

SSN*

LICENSES (click + to add row)

State	Number	Date Issued (mm/yy)	Exp Date (mm/yy)

DEA & CSR (click + to add row)

State	Number	Date Issued (mm/yy)	Exp Date (mm/yy)

CERTIFICATIONS (click + to add row)

Name	Issue Date (mm/yy)	Exp Date (mm/yy)

EDUCATION (click + to add row); please do not leave employment gaps*

School	Field of Study	Degree	Dates Attended (mm/yy - mm/yy)	Address, City, State, Zip

EMPLOYMENT HISTORY (click + to add row)

Facility	Job Title	Address, City, State, Zip	Start Date (mm/yy)	End Date (mm/yy)	Reason for Leaving

References (3 Required)(click + to add row)*

Name	Institution	Relationship	Phone	Email

Questionnaire

What was the date of your last patient contact?*

Have you ever had your license or privileges investigated, placed on probation, suspended, denied or revoked?*

Yes
No

Please describe

Have you ever been accused of criminal activity, treated for substance abuse, or accused of sexual misconduct?*

Yes
No

Please describe

Have you ever been named in a malpractice claim?*

Yes
No

How many total claims?*

Please describe each claim against you

Description	Year	Outcome	Payout

Are you aware of any incident reporting on the FSMB or NPBD?*

Yes
No

Please describe

By clicking the box below as my signature for this application, I agree that:*

I acknowledge I have read and agree to all terms and conditions listed below

I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate and complete. I also understand that the omission, concealment or misrepresentation of any facts on this application or during the interview process for any position with Locums Unlimited can be grounds for immediate privileging, licensing, and credentialing application withdrawal and/or cancellation of assignment. I understand this application is considered a legal document. The acceptance of terms and submission of this application acts as my signature and acceptance of aforementioned terms herein.

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