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Overview of physician information
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4
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Name
*
First
Last
Email
*
If Available, Please List the Reference ID below
What brought you to complete this form?
Marketing Email
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Address
*
Street Address
City
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Armed Forces Americas
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State
ZIP Code
Primary phone
*
Home phone
Office phone
Best times/days to call?
About you
I am a ...
*
Physician
Physician Assistant
Nurse Practitioner
Other
Where did you earn your medical degree and what year did you graduate?
*
Indicate which applies:
*
Board certified
Board eligible
Neither
If you have a specialty, list it here.
Specialties I would also consider include:
Please indicate which, if any, of the following areas of practice you are considering at this point in your career
Select All
Emergency room
Primary Care/General Practice
Urgent care
Hospitalist/Internal Medicine
If the Area of Practice is not listed above, please list below
List the state(s) where your license is active.
*
Will you consider relocating?
*
Yes
No
Would you be relocating alone?
Yes
No
Relocating with minors where schools are a consideration?
Yes
No
List states and cities that you would prefer. (list in preference order)
USA citizenship status:
*
Naturalized or born in USA
Work visa or green card holder
Other
Foreign languages spoken:
Why are you seeking new employment?
Date you are available for a new position?
MM slash DD slash YYYY
Type of placement you desire: (choose any you want)
Select All
Permanent
Locum Tenens
Locum to permanent
What type of practice peaks your interest?
Solo
S/S Group
M/S Group
Employed Position
Partnership
Traditional IP/OP
IP Practice
OP Practice
Any
Desired hourly compensation (locums):
Desired permanent placement salary (annual):
What EMR software programs do you have experience with?
Exceptions
Do you have problems with licensing or privileges?
Any malpractice suits?
Any past treatment for drug and/or alcohol abuse?
Is there anything on your National Practitioner Database Report that would affect your placement?
Not Applicable
If any of the following apply to you, please select the box above and provide a brief explanation in the space provided below your signature. Supporting documentation may be required at a later time or can be emailed separately to appexceptions@physicianproviders.com
Signature
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Please Briefly Explain Licensing/Privilege Issues Below
*
Please Briefly Explain Malpractice Suits Below
*
Please Provide Past Treatment Details Below
*
Please List Issues Found on your National Practitioner Database Report Below
*
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