Credential Form — LocumTele

Basic Information

All Information Must Be Complete

** We need DEA# and SS# to verify DEA. If info is missing, this form will not be processed. Our malpractice carrier requires this information. If anything is pending, please indicate pending **

Check Profession

MD DO PA NP

First name

Initial

Last

Phone number

Mobile Number

Mailing Address

City

State/Province

Zip/Postal

Country

Practice Address

City

State/Province

Zip/Postal

Country

Date of Birth

Speciality

NPI#

Medicare Validated (if applicable)

Education (MD, DO, ADN, BSN, MSN, PhD)

Medical or Nursing School (Please List the School You Attended)

Year Of Graduation

Post Graduate Education

Year Of Graduation

Are you Board Eligible? (Physicians)

Are you Board Certified? (Physicians and Nurses)

If yes, which Board? (Physicians and Nurses)

Certification Number (Physicians and Nurses)

Gender

Do you own your own practice?

Language(s) spoken? (other than English):

Professional References

Please add 2(two) professional references, that have worked with you for the past year, that we can contact for a Professional Reference.

First and Last Name

Phone Number

First and Last Name

Phone Number

DEA Registration

If you don’t have a DEA, please explain. You can work without one, but we need to know the status.

DEA Registration

I have a DEA and will forward you my number. (*Note, I must have a Social Security Number and a valid DEA number in order to verify the DEA.) I don’t hold a DEA & I have no plans to apply for one I hold a Government/Fee waived DEA My DEA is Pending

Additional informaton about DEA Registration (if applicable)

DEA Number

Expiration Date

Active Licenses and Registrations

(Medical, Tele, Locums, RN, NP, etc., and/or Controlled Substance)

State

Type

Number

Expiration Date

State

Type

Number

Expiration Date

Additional active licenses / registrations

Non-Active Licenses and Registrations

(Expired, Lapsed, Superseded, Surrendered)

State

Type

Number

Expiration Date

Additional non-active licenses / registrations

Work Schedule

Enter in work schedule information.

Are You Interested In Working:

Full Time Part Time

Hours

CV & Other Documents Upload

* PLEASE NOTE: If you are licensed in Mississippi, please forward a copy of your license.

If you have trouble submitting your CV or other documents, please email them to info@locumtele.org

If you are a RN-BC or NP-BC or APRN-BC, please send the board certification.

CV File Upload

Licensure And Claims History

* If you answer "Yes" to any question, please provide a detailed explanation *

Have you ever been the subject of disciplinary or investigative proceedings or reprimand by a governmental, administrative agency, hospital or professional association?

Yes No

Have you ever had any State professional license or license to prescribe or dispense narcotics refused, suspended, revoked, renewal refused, or accepted only on special terms or voluntary surrender of same?

Yes No

Have your hospital privileges and / or professional services ever been denied, revoked, suspended, refused, limited, placed on probation or placed under any disciplinary action?

Yes No

Have there been or are there any pending malpractice claims, judgments, suits, settlements, or notices of intent to commence action involving you?

Yes No

Have you ever been convicted of an act committed in violation of any law or ordinance other than a traffic violation?

Yes No

Do you have now or have you ever had any problems with or been treated for drug or alcohol dependency?

Yes No

Have you ever had or do you now have any physical or mental condition that would compromise your ability to practice medicine or perform clinical assignments?

Yes No

If you answered yes to any of the above, please explain in detail below.

Declaration of Health

I hereby declare that, to the best of my knowledge, I do not have a physical or mental condition that would adversely affect my ability to carry out the clinical privileges, which I have requested as a LocumTele physician.

Attestation, Authorization and Warranty

I authorize LocumTele to release information to its Risk Management Department, insurance companies, and medical facility clients. I hereby authorize the disclosure by any institution (including but not limited to the Federation of State Medical Boards and State Licensing Boards) information regarding me, including my education, medical training and employment, skills, experience, fitness to practice medicine, character, work habits, job performance, certification, licensure, hospital staff or clinical privileges, DEA authorization and medical malpractice claims. The undersigned releases the above from any claims resulting from the disclosure of such opinions to LOCUMTELE. I authorize the release of all information from Medical Schools, Colleges, Universities, Medical Institutions, Hospitals, Clinics, Physicians, State Medical Boards, Medical Malpractice Carriers, All Government Agencies, and any other source necessary to assist with my credentialing process. I understand that all information will be used to evaluate my professional qualifications, assist with credentialing at Health Care Facilities, and for use when applying to State Medical Boards for licensure are necessary.

Todays Date

Authorization to use electronic signature

I hereby opt-in to using an electronic signature, as typed below. By typing my full name below, I am consenting and accepting to this being used as my electronic signaure for LocumTele records.

Electronic Signature: Please type full name with title.