Complete in full, initial and date all pages, and sign and date the last page.

Transcription

1 Physician Document Checklist Document Checklist Document Name Provider Application Provider Service Agreement (PSA) Release and Authorization (R & A) Current Curriculum Vitae (CV) Independent Contractor Declaration Description Complete in full, initial and date all pages, and sign and date the last page. Sign and Date last page. Print your name, sign, and date. The CV must include your work history from receipt of medical degree to present. All dates must include month and year and not contain any gaps in time. This form acknowledges that you are an independent contractor. Print your name, sign and date. W-9 Must include printed name, signature, date, address, tax classification, taxpayer ID number or social security number. 1st and 3rd party documentation for all malpractice claims 1st and 3rd party documentation for all disciplinary actions If applicable. If applicable. Additional Requirements Submit the following documents below in addition to the items listed above: State License Copy CSR License (if applicable) DEA Medical School Diploma Post Grad Certificates Board Certification Certificate (if applicable) ECFMG Certification (International Graduates) Form DD214 (Military Applicants) Questions or Concerns If you have any questions or concerns about any of the documents listed above, do not hesitate to contact us: Search available positions on your mobile device at consiliumstaffing.com Or Scan in QR code

2 Independent Contractor Application for Physicians Personal Information First Name Last Name Middle Name Suffix Address City State Zip Code Home Phone Work Phone Cell Phone Address Date of Birth (mm/dd/yyyy) Place of Birth (City, State, Country) SSN Are you legally able to work as an independent contractor in the United States? Driver License Number State Emergency Contact Name Relationship Phone Number Address Education Name of Medical School Degree Start Date (mm/yyyy) City State/Provence Zip Code Country Completion Date (mm/yyyy) ECFMG # Year Times Taken Post Graduate Training Facility Completed Training Type Internship, Residency, Fellowship Start Date (mm/yyyy) Specialty City State Phone Completion Date (mm/yyyy) Facility Completed Training Type Internship, Residency, Fellowship Start Date (mm/yyyy) Specialty City State Phone Completion Date (mm/yyyy) Facility Completed Training Type Internship, Residency, Fellowship Start Date (mm/yyyy) Specialty City State Phone Completion Date (mm/yyyy) Facility Completed Training Type Internship, Residency, Fellowship Start Date (mm/yyyy) Specialty City State Phone Completion Date (mm/yyyy) 1 of 4 Initials Date

3 Independent Contractor Application for Physicians Board Certification Specialty Board Certified Date (mm/yyyy) Re- Certified Date (mm/yyyy) Specialty Board Certified Date (mm/yyyy) Re- Certified Date (mm/yyyy) If not Board Certified, are you eligible to take a specialty exam? If not Board Certified, how many times have you failed to pass the exam? Life Support (Provide Copies) BLS ACLS ATLS PALS Other Military Service (Provide Form DD214) Military Branch Dates of Service (mm/dd/yyyy) Type of Discharge From: To: Medical Licenses (List All Active and Inactive Licenses) Provide Separate Sheet if needed. State License # Date Issued (mm/yyyy) Expiration Date (mm/yyyy) Controlled Substance # Date Issued (mm/yyyy) Expiration Date (mm/yyyy) Federal Drug Enforcement Registration Date Issued (mm/yyyy) DEA # Exempt Expiration Date (mm/yyyy) DEA # Exempt Date Issued (mm/yyyy) Expiration Date (mm/yyyy) Department of Transportation DOT # Date Issued (mm/yyyy) Expiration Date (mm/yyyy) Insurance Billing NPI # USER ID PASSWORD CAQH ID# USER ID PASSWORD 2 of 4 Initials Date

4 Independent Contractor Application for Physicians Questionnaire If you answer Yes to any of the following questions, provide 1 st party documentation with this application. 1. Have you ever been denied certification by a Specialty Board or not been allowed to take an exam for any reason? 2. Have any of your licenses, active or inactive, past or present, ever been limited, suspended, revoked, surrendered, reprimanded, admonished, placed on probation, investigated or placed under any other corrective action? 3. Have you ever been denied a medical license by any licensing board, or have you withdrawn an application for a medical license for any reason? 4. Has your DEA/Narcotics license ever been suspended, revoked, limited, voluntarily surrendered, or placed on probation? 5. Have you ever been denied membership or renewal thereof or been subject to disciplinary action by any medical organization or entity? 6. Have you ever failed to satisfactorily complete any portion of any training program? 7. Have you ever been terminated from employment or while working as an independent contractor? 8. Have you ever been sanctioned or investigated by Medicare and/or Medicaid? 9. Have your hospital privileges ever been denied, suspended, revoked, withdrawn or placed under any disciplinary actions, or have they ever not been renewed for any reason other than your own voluntary decision not to practice at that particular facility and/or time? 10. Have you ever received treatment for substance abuse or alcoholism? 11. Have you ever been convicted of a felony offense? Professional Liability If you answer Yes to any of the following questions, please complete a supplemental form for each claim and attach 3 rd party documentation from your malpractice carrier, attorneys, NPDB query or any other viable source, and for any and all claims within the last 10 years. 1. Have you had any malpractice suits dismissed, settled, or closed without payment? If yes how many? 2. Have you had any malpractice suits dismissed, settled, or closed with payment? If yes how many? 3. Are you currently the subject in any pending medical malpractice claims or suits? If yes how many? 4. Have you ever been denied malpractice insurance? If yes, please explain: 3 of 4 Initials Date

5 Independent Contractor Application for Physicians References (List only references with whom you have had clinical contact in the past 12 months. References should only be listed if they are able to directly comment on and rate your clinical skills and competence, quality of work, patient care, charting, documentation, etc ) **Required Referrals Please list any colleagues that may be interested in locum tenens. Name Specialty Phone Name Specialty Phone Consent I confirm that the information provided on this application is true and complete. I understand that, LLC will use this information to determine my qualifications to be approved for medical malpractice insurance and eligibility for locum tenens assignments or placements through, LLC. I acknowledge misinformation, omissions, or misrepresentation, intentional or not, will be just cause for immediate disqualification. I agree to hold, LLC and its staff harmless from any and all claims, actions, damages, judgments, accusations, and expenses arising from their acts in connection with the procuring, verification, and distribution of information provided by me in evaluation of this application, credentials, and qualifications. My signature below verifies that I accept the terms and conditions described above and I submit this Independent Contractor Application for consideration with LLC. X Provider Signature Print Name Date (mm/dd/yyyy) 4 of 4

6 Independent Contractor Declaration Independent Contractor Declaration Revision (4/24) The undersigned service provider (the Provider ) declares, acknowledges and agrees that he/she is an Independent Contractor and is not an employee of, LLC or any of its affiliates or contracted facilities. 1. I am a licensed, trained healthcare provider engaged in the practice of providing medical care to patients in my specialty of training and/or experience. 2. I am solely responsible for my professional actions and decisions in providing services to patients at the contracted healthcare facilities or elsewhere. 3., LLC will not at any time direct or control the manner of clinical decisions in which I practice my profession. 4. I independently determine the assignments I am willing to accept and the rate at which I will be paid for each assignment. I cannot be directed by, LLC to accept assignments. 5. I have the right to terminate my relationship with, LLC at any time and I may terminate an assignment with or without cause by giving thirty (30) days written notice. Such notice shall be confirmed receipt by, LLC for notice to be in effect. I will allow, LLC to communicate such notice to their Client. 6. To my knowledge,, LLC has no relationship with the healthcare facilities with whom I accept assignments other than that of a placement agency and I understand that, LLC is not licensed to nor is it engaged in the practice of medicine in any form. 7. I am not an employee of, LLC nor any Client contracting for services through the agency. As an independent contractor, I understand and agree that I am responsible for reporting and paying all federal, state and local income or self-employment tax due on payments received as a result of accepting and completing an assignment. In addition, I am NOT entitled to claim unemployment benefits for or worker s compensation against, LLC or contracted facilities and attest I am not a nonresident alien. 8. To the extent I receive payments from, LLC in relation to all assignments; such payments are made to me by, LLC as an independent contractor on behalf of the services performed at any of the clients for who the assignment is performed. This Declaration is a true and correct statement of the facts set forth herein. This declaration is executed effective as of 20. PROVIDER, LLC Signature X Signature X Name (Print) Name (Print)

7 Release & Authorization Revision (2/11) Release & Authorization By signing the below, I certify that the information on this application is true and complete to the best of my knowledge. I authorize, LLC to release information contained in this application, or obtained by, LLC pursuant to its credentials verification processes also authorized by this paragraph, to its clients, and to query the National Practitioner Data Bank, DEA, Federation of State Medical Boards, State Licensing Boards, insurance companies, and any other necessary source. I waive any claims I might otherwise have against, LLC for releasing information as authorized by this paragraph. I release, LLC and/or its agents and any person or entity, which provided information pursuant to the Authorization for Obtaining and Investigative Consumer Reports from any and all liabilities, claims, or lawsuits in regards to the information obtained from any and all referenced sources used. I understand that I have the burden of providing accurate and adequate information to, LLC, its affiliates or successors, to demonstrate my qualifications. I understand that any misstatement in this form may constitute grounds for denial of referral to practice opportunities, ground for civil damages, and grounds for reporting to the NPDB or state licensing boards or cancellation of contract. If any material changes occur affecting my professional status, it s my obligation to notify Consilium Staffing, LLC or the appropriate affiliate or successor as soon as possible. I attest that the information in this application is correct and complete. A copy of this document shall be acceptable proof to anyone receiving it of my full authorization. Name (Print) Signature X Date

8 Form W-9 (Rev. January 2011) Department of the Treasury Internal Revenue Service Name (as shown on your income tax return) Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. Business name/disregarded entity name, if different from above Check appropriate box for federal tax classification (required): Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate Exempt payee Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Other (see instructions) Address (number, street, and apt. or suite no.) Requester s name and address (optional) City, state, and ZIP code List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the Name line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Social security number Employer identification number Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4. Sign Here Signature of U.S. person General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners share of effectively connected income. Date Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester s form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: An individual who is a U.S. citizen or U.S. resident alien, A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, An estate (other than a foreign estate), or A domestic trust (as defined in Regulations section ). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. Cat. No X Form W-9 (Rev )