24 Commerce St. #434, Newark, NJ 07102, T. (866) 495-4770 F. 862-352-2555
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 (Provider)
Print Name (Provider)
Date