• Basic Information

  • Select Your Profession:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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  • Professional Information

  • Do you own your own practice?*
  • Do you wish to be paid in your name or a corporation name such as an LLC, PLLC, S-CORP, etc?*

  • Professional Information (Cont.)

  • Do you hold an active DEA Registration?*
  • Are you Board Eligible?*
  • Are you Board Certified? (Physicians and Nurses)*
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  • Professional References

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

  • CAQH Information

  • Are you registered with CAQH?*
  • Is your CAQH up to date?
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  • DEA Registration

  • What is your DEA Status? Please Note: You can work with some clients who do not require a DEA; however, we need to know the status.*

  • Active Licenses and Registrations

  • Non-Active Licenses and Registrations

  • Work Schedule

  • Are you interested in working:*
  • Please select from below:*

  • Preferred Types of Consults

  • Please select the types of consults you are interested in:*

  • CV and Other Document Upload

  • PLEASE NOTE:

    If you have trouble submitting documents, please email them to thrisa@locumtenensusa.com .

     

    PROVIDERS SUBMIT COPIES OF:

    1) Current  CV - Your information will not be processed without one.  (All Providers)

    2) Board Certifications - (Physicians, NP’s and APRN’s)

    3) Mississippi pocket card - (MD’s and DO’s)

    4) NNAAP or State Certification Certificate (CNA’s)

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  • Licensure And Claims History

  • 1. Have you ever been the subject of disciplinary or investigative proceedings or reprimand by a governmental, administrative agency, hospital or professional association?*
  • 2. 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?*
  • 3. Have your hospital privileges and / or professional services ever been denied, revoked, suspended, refused, limited, placed on probation or placed under any disciplinary action?*
  • 4. Have there been or are there any pending malpractice claims, judgments, suits, settlements, or notices ofintent to commence action involving you?*
  • 5. Have you ever been convicted of an act committed in violation of any law or ordinance other than a traffic violation?*
  • 6. Do you have now or have you ever had any problems with or been treated for drug or alcohol dependency?*
  • 7. Have you ever had any professional liability insurance company cancel, decline, refuse to renew, or accept only on special terms, their malpractice insurance?*
  • 8. 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?*

  • 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 Locum Tenens physician.

  • Attestation, Authorization and Warranty

  • I authorize Locum Tenens USA, Inc. 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 LOCUM TENENS USA, Inc. 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.

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