| Provider Application


 
Upload CV:
(Word document preferred)  
Application Type:

General Information

       
Email Address:    
First Name:    
Middle Name:  
Last Name:    
Maiden Name:  
Date of Birth  (mm / dd / yyyy):    
Social Security Number:  


Licenses / Certifications

(please list all active and inactive licenses)


State Currently Active?
1. 
2. 
3. 
4. 
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7. 
8. 
9.  DEA   #

Are you currently certified by one or more of the American Board of Medical Specialties or American Osteopathic Association?   

If no, are you scheduled to take the exam?
Date scheduled to take the exam:
Have you ever taken any part of the examination and failed to pass?
If yes, how many times?
Did you graduate from a foreign school?
     ECFMG Certification #
Or Fifth Pathway?


Malpractice Claims History

Have you ever been named in a malpractice claim, suit or arbitration proceeding? 
              


Disclosure Questions

1. Are you authorized to work as an independent contractor in the United States? (i.e. Citizen or Green Card Holder)  

 
2. Do you have any obligations to any state/federal agency or military service? 

 

Have any of the following ever been or are currently in the process of being investigated, denied, revoked, suspended, restricted,  limited, placed on probation, been subject to disciplinary action, reprimand, voluntary relinquishment or fined?
3. Medical License 

 
4. Controlled Substance Registration 

 
5. DEA Registration 

 
6. Other Professional License/Registration 

 
7. Clinical Privileges 

 
8. Membership on any Medical Staff 

 
9. Membership to any Healthcare Institution 

 
10. Academic Appointment 

 

11. Has any insurance carrier ever denied, cancelled, refused to renew, restrict or rate up professional liability insurance? 
 
12. Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action by any managed care organization (including HMOs, PPOs, or provider organizations such as IPAs, PHOs)? 
 
13. Were you ever investigated, placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education? 
 
14. Have you ever voluntarily resigned or been terminated while under investigation? 
 
15. Have you ever been investigated, disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other private, federal or state governmental health care plans or programs? 
 
16. Have you ever received sanctions from or been the subject of investigation by any regulatory agencies (e.g. CLIA, OSHA, etc.)? 
 
17. Have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospital, facility or agency, or voluntarily terminated or resigned while under investigation by a hospital or healthcare facility of any military agency? 
 
18. Have you been charged and/or convicted of a felony or misdemeanor other than a traffic violation? 
 
19. Are you currently abusing alcohol, using illegal drugs or failing to take legally prescribed drugs in the manner prescribed? 
 
20. Have you ever been treated or are you currently being treated for alcoholism or narcotic addiction including inpatient, outpatient or counseling? 
 
21. Do you use any chemical substance that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety? 
 
22. Have you ever been treated or are you currently being treated for mental illness including inpatient, outpatient, or counseling? 
 
23. Do you have any reason to believe that you would pose a risk to the safety or well-being of your patients? 
 
24. The essential function of a locum tenens physician is to provide a standard of care that is acceptable within his/her specialty. Is there anything that would prevent you from performing this function with or without reasonable accommodations? 
 

Release of Information

The applicant declares that to the best of his/her knowledge the statements herein are true. Signing of this Application does not bind the undersigned to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a Policy be issued, and that this Application will be attached and become part of such Policy, if issued. The insurance company and/or Delta Locum Tenens “DLT” are hereby authorized by Applicant to make any investigation and inquiry in connection with this Application, as they deem necessary, and to release information contained in the application or supplemental support documentation, (including but not limited to the application, references, background search results, etc.) to healthcare facilities which are seeking to fill its staffing needs with locum tenens healthcare providers. DLT may also share information regarding my employment with its affiliates and appropriate governmental or licensing entities. I hereby expressly release and discharge and will hold harmless DLT and the aforementioned entities, their agents, employees and/or representatives from any and all liability which might otherwise be incurred as a result of acts or omissions performed in connection with any inquiry, investigation or in the evaluation of information so received from whatever source.

It is agreed that in the event there is any material change to the answers in the questions contained herein prior to the effective date of the Policy, that I will notify DLT and, at the sole discretion of DLT, any outstanding quotations may be modified or withdrawn.

Further, I acknowledge and agree that any claims resulting from acts committed prior to the effective date of coverage are specifically excluded from coverage under this policy. I acknowledge that if I withhold information, mislead, or attempt to defraud or lie of any matter contained in this application, then such act will void the insurance policy.

The applicant shall cooperate with DLT in all respects in matters pertaining to this insurance and shall provide information, attend hearings and trials, and assist in making settlements, securing and giving evidence, obtaining the attendance of witnesses, and otherwise facilitating the conduct of any proceeding in connection with the subject matter of this insurance, as may be selected by DLT.

I agree with the statements above:  
Date: