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 **
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.
DEA Registration
If you don’t have a DEA, please explain. You can work without one, but we need to know the status.
Active Licenses and Registrations
(Medical, Tele, Locums, RN, NP, etc., and/or Controlled Substance)
Non-Active Licenses and Registrations
(Expired, Lapsed, Superseded, Surrendered)
Work Schedule
Enter in work schedule information.
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.
Licensure And Claims History
* If you answer "Yes" to any question, please provide a detailed explanation *
Declaration of Health
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.