Salient MD Provider Application

Full Name *

First Name Middle Name Last Name

E-mail *

Cell Phone Number: *

Area Code Phone Number

Age: *

Mailing Address (If Diiferent) *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Sex *

Marital Status *

Date of Birth: *

Month Day Year

Place of Birth

Social Security #: *

For criminal background check purposes only.

Citizenship

If Not a US Citizen provide Alien Registration Number

Driver's License Number

State of Driver's License Issuance

Driver's License Exp Date

Languages That I'm Fluent In: *

English Spanish German French Chinese Japanese Hindi

Desired Work Situation *

Will you work weekdays? *

Yes No

Will you work weekday evenings? *

Yes No

Will you work weekends? *

Yes No

Will you work holidays? *

Yes No

When can you start? *

Month Day Year Date Picker Icon

School Name

School Location

Start Date

End Date

High School

College

Graduate School

Medical School

If Medical School took longer than 4 years, please explain

If Medical School completed in a foreign country, provide ECFMG Certificate Number

Program Name

Program Location

Start Date

End Date

Internship

Residency

Fellowship

If there any gaps between Internship and Residency, and/or Residency and Fellowship, please explain

Check Applicable Status

If Board Eligible, list anticipated date of Board Certification

If Board Certified list Effective Dates

If Board Certified list Certification Number

If neither BE/BC, provide explanation

List in Chronological Order

Insusurer/Carrier

Policy Number

Effective Date

Contact

Policy A

Policy B

Policy C

Policy D

Policy E

List in Chronological Order

Hospital Name

Hospital Location

Medical Staff Category

Initial Credential Date

Hospital A

Hospital B

Hospital C

Hospital D

Hospital E

List in Chronological Order

Employer/Affiliated Entity

Location

Type of Work

Start Date

End Date

Entity A

Entity B

Entity C

Entity D

Entity E

Please provide four physician references. Please do NOT use immediate family or relatives.

Name

Entity

Relationship

Phone

Email

Ref 1

Ref 2

Ref 3

Ref 4

List All Current State Licenses

State

License Number

Expiration Date

State 1

State 2

State 3

State 4

State 5

Explain any Restrictions or Limitations

1. During your education, internship, residency, fellowship, preceptorship or additional training, as applicable were you ever disciplined, suspended, placed on probation, formally reprimanded, or asked to resign? *

Yes No

2. Have you ever been disciplined, reprimanded, or fined by any state board of medical examiners, professional conduct board, or state of federal agency that disciplines physicians or allied health professionals? *

Yes No

3. Has your license to practice, in your profession, ever been denied, limited, suspended, revoked, or subject to probation or any conditions or limitations in any state? *

Yes No

4. Have you ever been disciplined, suspended, sanctioned, or otherwise restricted from participating in any private, federal or state health plan program (forexample, Medicare, Medicaid, CLIA, professional society or managed care organization) or is any such action pending? *

Yes No

5. Have you ever been the subject of any investigation by any private, federal, or state health program – or is any such action pending? *

Yes No

6. Have your Federal DEA and/or State Controlled Dangerous Substance (CDS) Certificate(s) ever been voluntarily or involuntarily limited, suspended, revoked, relinquished, or not renewed – or are proceedings currently pending? *

Yes No

7. Has your professional liability insurance coverage ever been terminated or modified by action of any insurance company? *

Yes No

8. Have you ever been denied professional liability insurance coverage or rated in a higher-than-average risk class for your specialty? *

Yes No

9. Have any professional liability suits, actions, or claims alleging malpractice ever been filed against you? *

Yes No

10. Are any professional liability suits, actions or claims currently pending against you? *

Yes No

11. Have any judgments ever been made against you in professional liability cases or claims, or have you ever entered into any settlements? *

Yes No

12. To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank? *

Yes No

13. Are you currently uninsured for professional liability staff (malpractice insurance) coverage?

Yes No

14. Have your medical membership or clinical privileges at any hospital or healthcare institution or organization ever been limited, suspended, revoked, not renewed, or subject to probationary or other disciplinary conditions; or have proceedings toward any of these ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board?

Yes No

15. Has your request for any specific clinical privileges been denied or granted with stated limitations (aside from ordinary or initial requirements of roctorship), or has such a denial or limitation been recommended by a medical staff or peer review committee to a governing board?

Yes No

16. Have you ever had any previous or pending challenges to, or voluntarily or involuntarily relinquished any medical staff membership or clinical privilege(s), as the re6ult of any investigation or disciplinary action?

Yes No

17. Have you ever been court-martialed, sanctioned, reprimanded, or cautioned by a hospital or any other healthcare facility or military agency; been involuntarily terminated or forced to resign; or have you resigned voluntarily while under investigation or threat of sanction from a hospital or healthcarefacility or any military agency?

Yes No

18. Has your Specialty Board certification or eligibility ever been denied, revoked, relinquished, not renewed, suspended, or reduced – or have any proceedings toward those ends been instituted?

Yes No

19. Do you have, or have you had, a chemical dependency and/or substance abuse problem - treated or untreated?

Yes No

20. During the last three years, have you ever been under the influence of alcohol or drug or chemical substance during working hours?

Yes No

21. Are you unable to practice to the fullest extent of your license, qualification, and privileges without posing a risk of harm to your patients?

Yes No

22. Have you ever been arrested for, or charged with, a crime involving children? If "Yes,"include the disposition of the arrest or charge on a separate sheet. This statement is being answered under penalty of perjury, subject to applicable Federal punishment of perjury.

Yes No

23. Have you ever been convicted of, or indicted for, or presently under investigation for, a felony?

Yes No

24. Have you ever been convicted of, or indicted for, or presently under investigation for, a felony?

Yes No

If you answered "Yes" to any of the preceding questions, provide an explanation along with a reference to the question number

I represent that the information provided in or attached to this Application and the most current information provided to Salient MD and its Affiliated Entities is accurate and complete. I understand that a condition of this Application is that any misrepresentation, misstatement or omission from this Application, whether intentional or not, is cause for automatic and immediate rejection of this Application by Salient MD and its Affiliated Entities and may result in denial of my application or termination of my participation with Salient MD and its Affiliated Entities. I further understand that any misrepresentation, misstatement or omission from this Application, if discovered after participation has been awarded to me, may lead to immediate suspension or termination of my relationship. I agree to use my best efforts to inform Salient MD and its Affiliated Entities in writing within 30 days if there is any change in the information provided or the answers to questions on the Application as a result to developments subsequent to my signing this Application.

I warrant that I have the authority to sign this Application, on my behalf, and on behalf of any entity or organization for which I am signing in a representative capacity. I agree that submission of this Application does not constitute approval or acceptance of this application or me by Salient MD and its Affiliated Entities as a participating provider or independent contractor. I further agree that this application may only qualify as a "pre-application" under the rules of the entity.

I warrant that I been hereby warned that intentional or unintentional false statements and the like so made may jeopardize the validity of this Application; declare that I am properly authorized to execute this Application; and that all statements are true.

Signature

Clear

Note: Entities affiliated with Salient MD include Salient Locums, LLC and Salient Health Services, Inc.

I hereby give permission to Salient MD and its Affiliated Entities and/or its designee to request information regarding my professional credentials and qualifications from educational facilities, the chief(s) of the clinical department(s) of the hospital(s) in which I currently have or formerly have had medical staff membership and/or clinical privileges, professional certification boards, state regulatory and licensing departments, professional liability insurance carriers, other professional monitoring entities, and present and past employers.

The information requested may include otherwise privileged or confidential material relative to my professional qualifications, credentials, claims history, clinical and/or professional competence, character, ethics, or any other matter having bearing on the credentialing procedure. I release and agree to hold harmless Salient MD and its Affiliated Entities to whom this information is given and their representatives, employees and agents from any and all liability for any damages, costs, and expenses which may result from the gathering or use of such information, as long as such release or use of information is done in good faith and without malice.

I hereby authorize the educational facilities, the chief(s) of the clinical department(s) of the hospital(s) in which I currently have or formerly have had staff privileges, professional certification boards, state regulatory and licensing departments, professional liability carriers, other professional monitoring entities and present and past employers to submit information requested by Salient MD and its Affiliated Entities including otherwise privileged or confidential material relative to my professional qualifications, credentials, past and present malpractice coverage, claims and suit information, clinical and/or professional competence, character, ethics, or any other matter having bearing on the credentialing procedure. I hereby further release and agree to hold harmless Salient MD and its Affiliated Entities, their representatives, employees and agents from any and all liability for any damages which may result from providing this information, as long as such release or use of this information is done in good faith and without malice. I further agree the burden shall be upon me to prove such release was done in bad faith and with malice by a preponderance of evidence.

I authorize Salient MD and its Affiliated Entities to obtain information about me from a consumer reporting agency for “engagement” purposes. I understand that I may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about my character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as my neighbors, friends, or associates. These reports may include employment history and reference checks, criminal and civil litigation history information, motor vehicle records (“driving records”), sex offender status, credit reports, education verification, professional licensure, drug testing, Social Security Verification, and information concerning workers’ compensation claims. I have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report.

I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this authorization and, if I am engaged, throughout my “engagement”. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Salient MD and its Affiliated Entities or another outside organization acting on behalf of Salient MD and its Affiliated Entities.

I hereby consent to submit to a drug or alcohol screening tests; and to furnish a sample of my urine, breath, and/or blood for analysis. The specific panel of tests shall be determined by Salient MD (or one of its Affiliated Entities and/or one of its Clients where I may be placed), consistent with either Salient MD’s or a Client’s Policy regarding the screening and credentialing of applicants. I further authorize and give full permission for the designated laboratory or other testing facility to release any and all results and documentation relating to such test to Salient MD. I authorize Salient MD to share these same results with any of their Clients wherein I am in the process of being credentialed. I understand that evidence of current use of illegal drugs, or excessive use of alcohol or any controlled substance, will prohibit me from being contracted with Salient MD or any of their client facilities. I further agree to hold harmless Salient MD and its agents from any liability arising in whole or part, out of the collection of specimens, testing, and use of the information from said testing in connection with Salient MD’s consideration of my application.

I agree that a photocopy or facsimile of this document with my signature may be accepted by any person or entity from which such information is sought with the same authority as the original and I specifically waive written notice from any such entities or individuals who may provide information based upon this authorized request.

Signature

Clear

CV

Photo

Medical School Diploma

Internship Certificate

Residency Certificate

Fellowship Certificate (if Applicable)

Board Certification Certificate

Current Driver's License

Current State Medical License(s)

DEA Registration

Controlled Substance Certificate(s)

Professional Liability Certificates of Coverage (COI's - up to five most recent)

ECFMG Certificate (if applicable)

ACLS/BCLS/ATLS Certificate(s)

Residency Program Director Attestation regarding Your Completion

AMA Recognition Award for CME

Copy of current TB Skin Test

Passport style photo (as JPEG file)

Certified copy of birth certificate or copy of valid passport

Copy of marriage or divorce certificate verifying name change (if applicable)

Personal Information

Educational Experience Through Medical School

Internship, Residency, and Fellowship Experience

Board Eligibility/ Board Certification

Professional Liability/Med Mal Coverage History

Hospital Affiliation History

Work History as a Physician

Professional References

Medical Licenses

DEA Registration

Controlled Substance Certificate(s)

Clinical Certifications

Provider Identifiers - Credentialing Related

Professional Attestations

Authorization to Release and Secure Information

Document Upload

Additional Documents Need