WTH Physician Extender Application

WTH Physician Extender Application
Please complete the following information necessary to apply for the position of Physician Extender. If you are currently under contracted service with any other employer or entity please indicate that in the space provided below.

Each physician extender applicant must have proper authorization and must be cleared by a West Tennessee Healthcare (WTH) Human Resources Department Representative prior to assuming the requested physician extender role. If you have any questions regarding the authorization process please contact the Human Resources Department at (731)265-1120.

* Indicates required information

If you have any questions please contact the Human Resources Department at (731)265-1120
Personal Information
First Name*
Middle Name
Last Name*
Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Home Phone*
Please enter a valid phone number.
Work Phone*
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Employment Information
Current Employer*
Date of Hire*

MonthDayYear
Date
Current Position*
Provide Position Type
Office Manager*
Office Practice Type*
Current Title*
Provide Title
Primary Sponsoring Physician*
List All Active state licenses/license numbers and/or certifications*
Current Classification*
Choose the specialty (i.e. job description) that you will function in for this role:*
Education
Name of School*
City & State*
Diploma/Degree & Dates*
Education Additional
Name of School
City & State
Diploma/Degree & Dates
Can you perform the essential functions of the position for which you have applied, with or without the accommodation by the facility?
Background
Are you now, or have you ever been engaged in any illegal drugs which would prevent you from safely performing the essential functions of your job?*

NoYes
If you answered yes, please explain.
Have you ever been convicted of a crime?*

NoYes
If you answered yes, please explain.
Is or has your professional license or a certification ever been under investigation, suspended, or had disciplinary action taken against it?*

NoYes
If you answered yes, please explain.
Are you currently an employee of West Tennessee Healthcare?*

NoYes
If yes, please provide your Department, Date of Hire, Job Title and Name of Supervisor:
Have you previously worked for West Tennessee Healthcare?*

NoYes
If so, please provide your Job Title, Department, Dates of Employment and Reasons for leaving:
Signature
By typing my name in the place provided I certify that the facts in this application are true and accurate to the best of my knowledge. I authorize investigation of all statements given concerning previous positions.*
Ex: John/Jane H Smith
By typing my name here, I know that any material omission or misrepresentation shall be sufficient for cause for termination from thePhysician Extender program.*
Ex John/Jane H Smith
By typing my name here, I authorize release of information obtained during the application process to all client affiliates.*
Ex: John/Jane H Smith
Anticipated Start Date:*

MonthDayYear
Should be Empty:

WTH Physician Extender Application

Personal Information

Employment Information

Education

Background

Signature