Physician Providers Credential Checklist

History

Have you ever been denied a medical license or had a license suspended/revoked or issued with limitations?*

Yes
No

Please explain*

Be prepared to provide supporting documentation is you answered yes to this question.

Have you ever been denied a DEA number or had a DEA number suspended/revoked or issued with limitations?*

Yes
No

Please explain*

Be prepared to provide supporting documentation is you answered yes to this question.

Have you ever been denied privileges at a hospital or had your privileges revoked/suspended or limited?*

Yes
No

If answer is yes, please explain and be prepared to provide supporting documentation at a later date.

Please explain*

Be prepared to provide supporting documentation is you answered yes to this question.

Have you ever been convicted of a felony or misdemeanor?*

Yes
No

Please explain*

Be prepared to provide supporting documentation is you answered yes to this question.

Have you ever been treated for drug or alcohol abuse?*

Yes
No

Please explain*

Be prepared to provide supporting documentation is you answered yes to this question.

Professional liability information

Has any insurance company ever cancelled, declined to issue, or refuse to renew professional liability insurance?*

Yes
No

Please explain*

Be prepared to provide supporting documentation is you answered yes to this question.

Have you ever been named in a malpractice suit?*

Yes
No

Has a judgement been reached?*

Yes
No

If you answer yes, you must explain and be prepared to provide supporting documentation.

Date judgment was reached.*

Please provide details.*

Professional Reference Information*

Please provide the name, title, and email address of a professional reference below (You are required to provide 3 total):

Professional Reference Information*

Please provide the name, title, and email address of a professional reference below (You are required to provide 3 total):

Professional Reference Information*

Please provide the name, title, and email address of a professional reference below (You are required to provide 3 total):

PPMC APPLICATION VERIFICATION AUTHORIZATION**

I hereby authorize Physician Providers Management Corp to verify my personal history through any facility, employer, agency or individual listed in the application and release Physician Providers and the facility or person to whom the inquiry is made from any and all claims or liability as a result of such inquiries. I verify that the information provided in the application is accurate and true. Any current or future agreement may be terminated and Malpractice shall be null in void should any of the information provided be found to be inaccurate. By typing my full name below, I am electronically agreeing to these terms.

Date

PPMC APPLICATION VERIFICATION AUTHORIZATION**

I hereby authorize all hospitals, medical institutions or organizations, personal references, employers (past and present), business and professional associates (past and present), all governmental agencies and instrumentalities (local, state, federal, or foreign), all university transcript offices, all medical schools, and the Federation of State Medical Boards to release to state licensing boards / Physician Providers Management Corp any information, files, or records required by that particular board and/or Physician Providers Management Corp for its evaluation of my professional, ethical, and physical qualifications for licensure. By typing my full name below, I am electronically agreeing to these terms.

Date*

Signature*

Date

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PPMC Application

Step 1 of 5

Personal and confidential information to establish employment account

Pay information

Licensure

Board certification

History

Professional liability information

State	License Number	Expires