Professional Membership (check all that apply)
Education and Training:
*If medical or other professional school was not in the United States,
Canada or Puerto Rico, please attach a copy of ECFMG Certificate.
Date you first started working
outside residency or internship?
CERTIFICATIONS AND LICENSURE:
(Legible photocopies are required for complete application.)
Specialty Board Certifications: (List all that apply.)
Sub-Specialty Board Certifications:
Active Professional Licenses:
(List all that apply. Legible photocopies are required for complete application.)
State Controlled Substance Registration Certificate: *Submit copy
DEA Certificate: *Submit a copy of your current DEA Certificate.
Inactive Licenses: (List all that apply. *submit copy)
List all positions since residency in chronological order.
Include military and clinical experience,
even if dates are concurrent. (Explain any gap of more than 30 days.)
List the names and addresses of physicians with whom you have
worked recently, who can
evaluate your skills in handling radiology responsibilities.
A minimum of four references are required.
The following sections require complete, thorough information. (Any "YES" answer under these sections of the application must be
explained on a separate sheet of paper. A narrative with as much information as possible will enable us to properly evaluate your answers.)
PLEASE BE ADVISED THAT THESE INCIDENTS OR CLAIMS WILL NOT BE COVERED UNDER ANY POLICY ISSUED BY THE INSURANCE
CARRIER FOR USA RADIOLOGY MANAGEMENT SOLUTIONS, LLC.
HEALTH STATUS SECTION:
1. Has any action, including any investigation, ever been undertaken (pending or completed) of your:
Current Malpractice Coverage:
Previous Malpractice Insurance Carriers: Must provide ten (10) years of history
Liability History: (Please read carefully.)
Please fully describe each and every malpractice claim or suit brought against you (past, present, or pending), on a different sheet. Give the
status of any claims/suits (active, inactive, closed, settled, abandoned, dismissed), the current reserve, the insurance carrier and/or the amount
of any payment made.
Are you aware of any events, serious incidents or dissatisfied patients which might give reason to believe a claim/suit may be brought against
you? If yes, describe the occurrence on a separate sheet and indicate whether the matter has been reported to any insurance carrier.
Notice: Any such events, incidents, claims or suits such as described above or which occurred prior to your affiliation with
USA Radiology Management Solutions, LLC will not be covered by the insurance which applies to practice with USA Radiology Management Solutions, LLC. Therefore, it is
imperative that you report these matters to your present carrier immediately, if you have not already done so. Purchase of additional coverage for
unreported matters relative to your current/prior practice may need to be discussed with your present insurance representative.
USA Radiology Management Solutions, LLC
Please include current copies of the following documents with your completed application:
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