Physician Providers Candidate Profile · Physician Providers

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Candidate profile

Overview of physician information

Step 1 of 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
- Job Board
- Website
Address*
Street Address City 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
CAPTCHA
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*
Untitled
- First Choice
- Second Choice
- Third Choice

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