List your University Sponsor Contact Name, Title, and Email Address or Phone # *
Cell Phone *
Other Phone
Degree * — Select Choice — Doctor of Medicine (MD) Doctor of Osteopathic Medicine (DO) Bachelor of Medicine, Bachelor of Surgery (MBBS) Bachelor of Science in Nursing (BSN) Physician Assistant (PA) Certification Nurse Practitioner (NP) Certification Doctor of Dental Medicine (DMD) Doctor of Dental Surgery (DDS) Doctor of Pharmacy (PharmD) Doctor of Veterinary Medicine (DVM) Doctor of Podiatric Medicine (DPM) Doctor of Optometry (OD) Doctor of Chiropractic (DC) Other
Florida Board License # (Please include the prefix. E.g., ME, OD, PA) *
List the names and address of the facilities where you will be providing clinical services. *
Medical or Surgical Specialty * — Select Choice — Anesthesiology Emergency Medicine Family Medicine Internal Medicine Neurology Neurological Surgery Obstetrics and Gynecology Ophthalmology Orthopedic Otolaryngology (ENT) Pathology Pediatrics Podiatry Psychiatry Pulmonology Radiation Therapy Radiology Surgery Other
If Other selected above, please define:
Medical or Surgical Sub-Specialty * — Select Choice — Abdominal Aerospace Medicine Allergy and Immunology Bariatric Broncho-Esophagology Cardiac Cardiovascular Disease Critical care Colon & Rectal Dermatology Diabetes Endocrinology Family Medicine – Includes Deliveries Family Medicine – Excludes Deliveries Forensic Medicine Gastroenterology General Genetics Geriatrics Gynecology Hematology Hand Hand & Neck Hematology Hospice/Palliative Care Hospitalist Infectious Disease Intensive Care Laryngology Neonatology Nephrology Nuclear Medicine Neurology Nutrition Obstetrics – Includes Deliveries Obstetrics – Excludes Deliveries Occupational Med Oncology/Neoplastic Diseases Ophthalmology Oral Surgery Ortho: Excludes Spine Ortho: Includes Spine Oncology Otology Otorhinolaryngology Otorhinolaryn/Plastic Pain Management Pathology Pediatrics Pharmacology, Clin. Physiatry/Physical Med & Rehab Plastic Surgery Podiatry Preventative Medicine Psychiatry Psychosomatic Med Pulmonology Radiology Rheumatology Rhinology Sclerotherapy Sports Medicine Other N/A
If Other selected above, please define:
If Other selected above, please define:
If YES selected above, list the states where additional services will be provided, and the % of time performing out of state services (>/-=50% or <50%)
If YES selected above, list the states where additional services will be provided, and the % of time performing out of state services (>/-=50% or <50%) (copy)
3. Has your license to practice medicine or your permit to prescribe drugs ever been denied, revoked, suspended, placed on probation, subjected to reprimand, voluntary surrendered or any other way limited, or has it been or is it currently under investigation? If YES, please attach a detailed written explanation. * — Select Choice — YES NO
4. Have you ever been or are you currently under a consent order? If YES, attach a copy of the consent order and its termination if applicable. * — Select Choice — YES NO
5. Have your hospital staff privileges ever been denied, suspended, revoked, placed on probation, voluntarily surrendered or in any other way restricted, or have they been or are they currently under investigation? If YES, please attach a detailed written explanation. * — Select Choice — YES NO
6. Has any insurance company ever cancelled, declined to issue or refuse to renew your professional liability insurance, or offered such insurance only on special terms, or have you been notified of such intent? If YES, please attach a copy of the cancellation notice or letter if applicable. * — Select Choice — YES NO
7. Have any claims been asserted or civil actions filed against you alleging errors or missions or against your employer or any other entity responsible for or alleged to be responsible for your patient care activities, or have you been notified that such an action will be filed? If YES, please complete a Claim Supplement form for each claim and civil action. * — Select Choice — YES NO
8. Have any judgments been made against you, or any out-of-court settlements been made on your behalf, from an event alleging medical errors or omissions that were not addressed in #7 of? If YES, please fully complete a Claim Supplement form for each claim. * — Select Choice — YES NO
9. Have you ever been convicted of a criminal offense or are or are you under investigation for criminal offense? If YES, please attach a detailed written explanation. * — Select Choice — YES NO
10. Have you been treated for alcoholism or drug addiction within the last five years? If YES, please attach a detailed written explanation including dates and locations of all treatments and the names of your supervising and monitoring physicians. * — Select Choice — YES NO
11. Have you incurred or become aware of having a condition that impairs your ability to practice your specialty? If YES, please attach a detailed written explanation. * — Select Choice — YES NO
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