24 Commerce St. #434, Newark, NJ 07102, T. (866) 495-4770 F. 862-352-2555
Write Yes or No next to each question. Please provide explanations for Yes answers in a separate document.
SR NO.
ATTRIBUTES
YES | NO | N/A
1
Has your medical license in any state ever been investigated, reprimanded, limited, denied, suspended, revoked, or surrendered, or have you ever received disciplinary or administrative actions of any kind on any license?
YesNoN/A
2
Have your privileges at any hospital ever been investigated, suspended, limited or revoked, even if they were subsequently reinstated?
3
During your medical education and training programs, were you ever put on academic or clinical probation, asked to repeat a rotation, had your privileges investigated, reprimanded, limited, denied, suspended, revoked, or were you subject to any disciplinary action of any kind?
4
Have you ever been denied membership or renewal thereof or been subject to disciplinary action by any medical organization?
5
Have you ever been involved, directly or indirectly, in a claim, potential claim or suit arising out of the rendering or failing to render professional services, even if the suit was subsequently dropped or dismissed?
6
Do you currently have any potential claims or suits, or are you aware of any claims or suits pending, rising from the rendering or failing to render of professional services?
7
Has your professional liability insurance ever been denied, canceled or renewal refused?
8
Has your DEA certificate ever been investigated, limited, denied, canceled, or renewal refused?
9
Have you ever been charged with or convicted of a felony or a misdemeanor, pleaded “nolo contender” or have you ever been placed on probation for any offense other than a traffic violation, including any charges that were dropped or reduced?
10
Has your participation in any private, federal, or state health agency or insurance program ever been investigated, limited, suspended, sanctioned or otherwise restricted, even if it was a voluntary opt-out?
11
Have you ever been addicted to a controlled substance that has affected your ability to perform the duties of a physician?
I certify that this information is true and complete to the best of my knowledge.
Identifying Information
Specialty
Last Name
First Name
Initial
Cell Phone
Home Address
Social Security Number
Home Phone
City
State
Zip
Date Of Birth
Weeks per year you would like to work?
Geographic Preferences
Federal DEA #
Expiration Date
Emergency Contact: (Name & Phone)
Email Address
NPI Number
Please list all Institutions attended. (Use a separate sheet if necessary)
Education Information
School
Dates Attend (From)
Dates Attend (To)
Degree
Street
Masters OR Physician Assistant Program Information
Other Graduate Education
Certification
Board Certified YesNo
American Board of:
Date Certified
Date Re-Certified
Additional Board Certification:
Subspecialty Certified:
Board Eligible? YesNo
Other Certification:
BCLS/Exp Date
ATLS/Exp Date
ACLS/Exp Date
APLS/Exp Date
References
Please list a minimum of four professional references. They must be able to attest to your specific medical abilities and have worked with you in the past 2 years.
Name
Relationship
Phone
Fax or Email
Licenses
Please list all active state medical licenses, using a separate sheet if necessary.
Number
Issue Date
Exp. Date
In which state did you obtain your original license?
Please list all state controlled substance licenses:
Please list all inactive licenses:
Memberships
List professional memberships in local, State and National Societies
Please ensure that your CV work history lists month and year for each activity and includes an explanation for any gap in employement or schooling greater than one month.
I certify that the information on this registration is true and complete to the best of my knowledge. I authorize First Connect to release information contained in this registration, or obtained by First Connect pursuant to its credentials verification processes also authorized by this paragraph, to its clients, and to query the DEA, AMA, FACIS, FSMB, insurance companies, and medical facilty clients. I waive any claims I might otherwise have against First Connect for releasing information as authorized by this paragraph.
(Please ignore, if you have resume)
Please list in chronological order all institutions (including hospitals, corporations, military assignments or government agencies) with which you have been affiliated since completion of post-graduate training.
Name, Complete Address, Phone
Affiliated Hospitals
Dates Worked
Status:
First Connect is a leading provider of Physician/Locum staffing services. Since our beginning in 2017, we have specialized in short and long-term physician locum tenens with unmatched benefits for you. The First Connect team of professionals is trained to provide you with interesting assignments, competitive compensation, a quick registration process, and a smooth transition to your new location. We provide you with the most up-to-date information on industry trends, practice management, and clinical data to enhance your career.
Our enclosed Quality Assurance packet is a vital link to our A+ rated malpractice insurance carrier. These simple forms provide the information we need to speed the internal onboarding and hospital credentialing processes and enables us to pursue licensure in other states on your behalf, should you desire to do so.
In addition to the forms in this packet, here is a short list of the documents we’ll need from you:
A current CV, including dates in mm/yy format and explanation for any gaps longer than 30 days in your work history
State license certificate or card, showing the current expiration date
State controlled substance registration, CDS, or BNDD certificate, if applicable
DEA certificate
Lifesaving certifications (BLS, ACLS, PALS, ATLS, NRP, ALSO, etc.)
Board certificate, if applicable
Medical school diploma
ECFMG certificate, if applicable
Internship diploma, if applicable
Residency diploma
Fellowship diploma, if applicable
NPDB self-query (instructions included)
Driver’s license (in color, please do not fax this as it will not be legible)
You can return these documents to our secure Careers fax at 862-352-2555 or email to Careers@Firstconnectlocums.com
For additional questions, please call (866) 495-4770 and ask for a member of our Quality Assurance Department.
Thank you for choosing First Connect, we look forward to working with you!
A National Practitioner Data Bank Self-Query is required for all providers. Please follow the instructions below to complete and submit an NPDB Self Query.
To start the process, go to: http://www.npdb.hrsa.gov/
What will I need?
Identifying information, professional school, and license
Credit card for the $5.00 fee
Email address
How long will it take?
It takes most people an average of 20 minutes to fill out the form. If you verify your identity online, in most cases a response will be ready within a few minutes. However, if you are unable to verify online, you will need to have your form notarized and mail it to the Data Bank, which may take a week or more.
Note: If you do not use your own credit card, you will not be able to verify your identity online.
How will you verify my identity?
You can verify your identity by answering financial based questions that only you would know. If you cannot answer these questions, you must visit a notary public to witness your signing and dating the "Individual Self-Query" form that attests to your identity. Using a notary requires you to mail the signed form to the Data Bank.
What will I get?
Once your identity is verified and your self-query has been processed, you will be able to view your response online and a paper copy will be mailed to you. If you’ve elected to mail in a notarized identity form, the response will be mailed to you.
Step By Step NPDB Self-Query Process:
Follow this link: https://www.npdb.hrsa.gov/ext/selfquery/SQHome.jsp
Click “Start A New Order”
When the pop-up acknowledge comes up
Click “I accept the terms”
Click “Submit and Continue"
On Type of Search screen, click “personal”
Go through the 4 steps
Subject Information
Payment
Review Information
Identity Verification
Wait for the results email to be delivered
Print/save your results and submit to Careers@Firstconnectlocums.com
I hereby authorize the following individuals and entities to release all information (documented, oral or other) about me in their possession to First Connect or its agents:
1. All hospitals at which I have ever held privileges, whether full or limited, temporary or permanent; and all hospitals at which I have ever received training.
2. All medical/osteopathic societies, education institutions, specialty boards, and other medical/osteopathic organizations with which I have been associated.
3. All other State or Canadian licensure boards, including the Federation of State Medical Boards, federal health agencies, and federal and state drug control agencies.
4. All licensed physicians, nurses or other health care professionals of any state or Canadian province.
5. All attorneys who have participated in civil or criminal actions in which I was named party.
I hereby release the above-named individuals and entities from all liability for the release of information to First Connect and its agents. I further release from liability any group or individual that provides information relating to my ability as a healthcare professional. I authorize First Connect to release information as needed to facilities, entities and medical organizations in the process of pursuing work in my profession and/or obtain hospital privileges, licensure or other medical professional qualifications on my behalf.
I further authorize First Connect or any of its duly authorized agents to make any investigations that they deem necessary to secure information concerning me which is relevant to the requirements for credentialing, and I further authorize them to release such information they now or in the future have concerning me to (i) any federal, state, county, or local governmental entity, (ii) any hospital or other health care facility, or (iii) any other person upon a showing that the release of this information is vital to the health, safety and welfare of the general public.
Signature:
Date: