DRW Health

Job Search
About
About DRW Testimonials News Sign Up for Updates on Open Positions
For Clinicians
For Facilities
Careers
Resources
Contact
Apply Now

Participating Physician Application

Participating Physician Application

Step 1 of 5

20%

General Information
Date
MM slash DD slash YYYY
Name*
Suffix
- MD
- DO
- NP
- PA
NPI#
Social Security
Date of Birth
MM slash DD slash YYYY
Place of Birth
Primary Practice Specialty
Are you eligible to legally work in the United States?
- Yes
- No
Primary Mailing Address
City State / Province / Region ZIP / Postal Code
Phone #
Cell #
Work #
Email
Professional Liability
Have you ever been involved in a malpractice claim (including dismissed actions)?
- Yes
- No
If yes, how many cases? **Attach supplemental claim form for each action**
Are there currently any pending medical malpractice claims or settlement involving yourself?
- Yes
- No
Has your Professional Liability insurance coverage ever been denied, limited or canceled?
- Yes
- No
Actions, Limits, Sanctions
Have any of the following been or in the process of being, investigated, denied, revoked, suspended or placed under other disciplinary actions?
Medical license in any state:
- Yes
- No
DEA
- Yes
- No
Employment
- Yes
- No
Hospital Privileges
- Yes
- No
Academic appointment
- Yes
- No

Education/Training
Undergraduate Education:
Address
City State / Province / Region ZIP / Postal Code
Medical School
Address
City State / Province / Region ZIP / Postal Code
Internship
Address
City State / Province / Region ZIP / Postal Code
Residency
Address
City State / Province / Region ZIP / Postal Code
Fellowship
Address
City State / Province / Region ZIP / Postal Code
Boards/Licensing
Board Certification
Active State Medical License(s)
Active State Controlled Substance Permits
DEA Registration#
Date issued
MM slash DD slash YYYY
Expiration Date
MM slash DD slash YYYY
ECFMG #
Date issued
MM slash DD slash YYYY
Expiration Date
MM slash DD slash YYYY

Professional Liability Insurance
Present Carrier
Policy #
Coverage limits
Expiration Date
MM slash DD slash YYYY
Years with company
Address
City State / Province / Region ZIP / Postal Code
Professional Experiences
Name of Practice or Institution
Was this a Locum Tenens Assignment
- Yes
- No
Phone
Address
City State / Province / Region ZIP / Postal Code
Dates of Affiliation
Position held
Name of Practice or Institution
Was this a Locum Tenens Assignment
- Yes
- No
Phone
Address
City State / Province / Region ZIP / Postal Code
Dates of Affiliation
Position held
Name of Practice or Institution
Was this a Locum Tenens Assignment
- Yes
- No
Phone
Address
City State / Province / Region ZIP / Postal Code
Dates of Affiliation
Position held
Name of Practice or Institution
Was this a Locum Tenens Assignment
- Yes
- No
Phone
Address
City State / Province / Region ZIP / Postal Code
Dates of Affiliation
Position held

References
Please give name, cell (not work) number, and email of physicians you have worked with in the past 2 years
Name
Phone
Specialty
Email
Name
Phone
Specialty
Email
Name
Phone
Specialty
Email
Name
Phone
Specialty
Email

RELEASE AND AUTHORIZATION
I hereby affirm that the information I have provided on this application and attachments is true and correct and that it can be relied upon by DRWANTED.COM. I hereby authorize DRWANTED.COM, its affiliates and successors to obtain any information that may be relevant to an evaluation of my professional qualifications, including disciplinary actions, other confidential or privileged information and other credentials. I authorize DRWANTED.COM to disclose and receive from current, prior or potential employers, information relating to my qualifications, ability and character to practice medicine, including information from the following sources: all medical schools, colleges, universities, transcript offices, medical institutions or organizations, hospitals, employers, personal references, physicians, attorneys, companies or agencies who may furnish my criminal background history, companies that perform drug screens, medical malpractice carriers or organizations, business and professional associates, all government agencies and instrumentalities, the National Practitioner Data Bank, the Federation of State Medical Boards, the American Medical Association, America Osteopathic Association, American Board of Medical Specialties, DEA, state licensing boards, specialty boards and any other pertinent sources. I hereby waive and release DRWANTED.COM, its officers, employees, agents and third parties which provide or receive information regarding my credentials including but not limited to the Federation of State Medical Boards and those entities listed above from any claims, causes of action, damages and expenses including reasonable attorney’s fees arising from or relating to the provision, collection, verification and dissemination of information about me. I agree to provide and authorize the release by DRWANTED.COM and their clients the following: a) vaccination records; b) reasonable documentation evidencing that I am in good health and free of communicable diseases; c) the result of and/or copy of my criminal background check; if any and d) the result of and/or a copy of my drug screen, if any. I attest that the information in this application is correct and complete. I understand that I have the burden of providing accurate and adequate information to DRWANTED.COM and its affiliates. I understand that any misstatement in this form may constitute grounds for denial or referral to practice opportunities, grounds for civil damages, and grounds for reporting the same
Signature
Date
MM slash DD slash YYYY
Please upload any required documents
Drop files here or
Max. file size: 50 MB.
Document Checklist
- Copy of CV
- Copy(ies) of Licenses
- Copy(ies) of Medical School Diploma
- Copy(ies) of Certifications
- Copy(ies) of Board Certifications
- ATLS (required for EM) / ACLS / BLS / ALSO / PALS
- NPI / UPIN
- DEA(s)
- CSR(s)
- Copy(ies) of Photo ID (Driver's License and/or Passport)
- Health Records / Vaccinations (MMR / PPD / Statement of Health)
- 3-5 references names including Phone #, Fax #, and Email
Malpractice Explanation Form
(Please complete a separate form for each claim or suit reported)
General Information
Claimant (Plaintiff’s) Name
Date of Incident
MM slash DD slash YYYY
Date of Claim
MM slash DD slash YYYY
Your Status
- Primary Defendant
- Co-Defendant
Payment: Amount of Settlement
Name of Insurance Carrier
Policy Number
Phone Number
Fax Number
Allegations
Allegations
Claimant (Plaintiff’s) Name
Date of Incident
MM slash DD slash YYYY
Date of Claim
MM slash DD slash YYYY
Your Status
- Primary Defendant
- Co-Defendant
Payment: Amount of Settlement
Name of Insurance Carrier
Policy Number
Phone Number
Fax Number
Allegations
Allegations
Claimant (Plaintiff’s) Name
Date of Incident
MM slash DD slash YYYY
Date of Claim
MM slash DD slash YYYY
Your Status
- Primary Defendant
- Co-Defendant
Payment: Amount of Settlement
Name of Insurance Carrier
Policy Number
Phone Number
Fax Number
Allegations
Allegations
Claimant (Plaintiff’s) Name
Date of Incident
MM slash DD slash YYYY
Date of Claim
MM slash DD slash YYYY
Your Status
- Primary Defendant
- Co-Defendant
Payment: Amount of Settlement
Name of Insurance Carrier
Policy Number
Phone Number
Fax Number
Allegations
Allegations
Claimant (Plaintiff’s) Name
Date of Incident
MM slash DD slash YYYY
Date of Claim
MM slash DD slash YYYY
Status of Claim
- Dropped
- Pending
- Settled out of Court
- Dismissed without
Your Status
- Primary Defendant
- Co-Defendant
Payment: Amount of Settlement
Name of Insurance Carrier
Policy Number
Phone Number
Fax Number
Allegations
Allegations

Job Search
About Us
For Clinicians
For Facilities
Careers
Resources
Contact

©2024 DRW Health | Web design and Development by Good Work Marketing