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Application

INSTRUCTIONS: Unanswered questions or illegible responses can impede the credentialing process and may cause a delay in initiating contract services with USA Radiology Management Solutions, LLC
* required field
Last Name:* First Name:* M.I.:
Title (M.D., D.O., Ph.D.):* Address:* Address Line 2:
City:* State:* Zip:*
Phone: Pager: Cell Phone:*
Fax: Gender: Birth Date:*
Birthplace:* Citizenship:* Married:
Spouse's Name: Specialty 1: Specialty 2:
SSN:* Email Address:* Tax ID #:*
NPI#: MO Medicare #: MO Medicaid #:
Continuing Medical Education (list all post graduate activities that you have attended, or for which you have received credit in the past two years):

Professional Membership (check all that apply)

ACR AMA RSNA ARRS
Other:

Military Status

Military Status:

Education and Training:

Premedical School of Graduation: Street Address: City/State/County:
From Date: To Date: Degree:
Medical School of Graduation (Post Graduate School): Street Address: City/State/County:
From Date: To Date: Degree:
ECFMG Certificate #: Date Passed:

*If medical or other professional school was not in the United States, Canada or Puerto Rico, please attach a copy of ECFMG Certificate.


Internships

Hospital: Specialty: Street Address:
City, State: Zip Code: From Date:
To Date: Program Director:

 


Residency

Completed? Hospital: Specialty:
Street Address: City, State: Zip Code:
From Date: To Date: Program Director:

 


Fellowships

Check if you are in the process of completing.
Institution: Type: Street Address:
City, State: Zip Code:

Date you first started working outside residency or internship?

From Date: To Date:

CERTIFICATIONS AND LICENSURE:

(Legible photocopies are required for complete application.)

National Board Certification:  Yes  No  Date:
US Medical Licensure Exam:  Yes  No  Date:
Flex Exam:  Yes  No  Date:

Specialty Board Certifications: (List all that apply.)

Board 1: Eligible Certified Date Received:
Board 2: Eligible Certified Date Received:

Sub-Specialty Board Certifications:

Board 1: Eligible Certified Date Received:
Board 2: Eligible Certified Date Received:

Active Professional Licenses: (List all that apply. Legible photocopies are required for complete application.)

State: Number: Date Issued: Date Expires:
Photocopy:

 


State Controlled Substance Registration Certificate: *Submit copy

Certificate Number: State: Expiration Date: EMS # (Alabama Only):

DEA Certificate: *Submit a copy of your current DEA Certificate.

Federal Certificate Number: Expiration Date: UPIN #:

Inactive Licenses: (List all that apply. *submit copy)

State: Number:

 

State Licenses Pending:

PROFESSIONAL EXPERIENCE:

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.)

From Date: To Date: Hospital/Practice:
Address: City/State: Position Held:
Type:  Part Time  Full Time  Dept. Head:

 

Gaps Explanation:

PROFESSIONAL REFERENCES:

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.

Name: Title: Phone:
Affiliation: Address: City,State,Zip:

 

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. Do you have a physical or mental health condition which may adversely affect your ability to competently and safely perform the essential functions of a practitioner in your specialty area of practice without posing a risk of harm to your patients?  Yes  No 
a) Have you been denied health, life, or disability insurance?  Yes  No 
2. Do you have a history of chemical dependency or substance abuse that may adversely affect your ability to competently and safely perform the essential functions of a practitioner in your specialty area of practice without posing a risk of harm to your patients?  Yes  No 
a) I will attest to the lack of present illegal drug use.:  Yes  No 
3. Can you perform these functions and the privileges which you have requested with or without reasonable accommodations? If 'NO', please explain.:  Yes  No 
Explanation:

INSURANCE SECTION:

1. Have you ever been denied professional liability insurance? Has your policy ever been canceled? Has your professional liability insurer ever refused to renew your policy or placed limitations on the scope of your coverage, or has any professional liability carrier ever expressed any intent to deny, cancel, not renew, or limit your professional liability insurance or its coverage?  Yes  No 
2. Have any malpractice claims, suits, arbitrations, or other proceedings, ever been brought or instituted against you?  Yes  No 

LEGAL SECTION:

1. Have you ever been convicted of a felony or are you presently indicted for a felony?  Yes  No 
2. Have you ever been or are you currently suspended or excluded from participation in any government program including Medicare or Medicaid, or have sanctions (including civil money penalties) ever been imposed against you by any governmental agency?  Yes  No 
3. Has any action been undertaken, whether still pending or completed, against you by any governmental agency or law enforcement body for your alleged failure to comply with laws, statutes, regulations, or other legal requirements which may be applicable to the practice of your profession or to rendering of service to patients?  Yes  No 

PROFESSIONAL SECTION:

1. Has any action, including any investigation, ever been undertaken (pending or completed) of your:

a) Status in good standing in any internship, residency, fellowship, preceptorship, or other clinical educational program?  Yes  No 
b) Professional school faculty position or membership?  Yes  No 
2. Have you ever been disciplined by any State Board of Medical Examiners or Professional Conduct Board or ever been reprimanded, or fined by any State agency that disciplines physicians or allied health professionals? Has your authorization to practice in any jurisdiction (State or County) ever been revoked, voluntarily/involuntarily suspended, or subjected to probation or any conditions or limitations?  Yes  No 
3. Have your privileges or membership in any hospital or institution ever been denied, voluntarily/involuntarily suspended, reduced or not renewed or have disciplinary proceedings been brought against you by any medical organization?  Yes  No 
4. Have you ever been denied membership or renewal thereof, or been subject to disciplinary proceedings by any medical organization?  Yes  No 
5. Has your DEA certificate ever been voluntarily/involuntarily suspended, revoked, or otherwise limited?  Yes  No 
a) Does your DEA reflect Schedule(s) 2, 2N, 3, 3N, 4, and 5? If 'NO', please explain.:  Yes  No 
6. Has any information pertaining to you, to the best of your knowledge, ever been reported to the National Practitioner Data Bank (NPDB)?  Yes  No 
If 'YES', attach a current copy of the report with an explanation.:

Current Malpractice Coverage:

Carrier: Policy Number: Liability Limits:
Dates of Coverage: Retroactive Date:

Previous Malpractice Insurance Carriers: Must provide ten (10) years of history

Carrier: Policy Number: Liability Limits:
Dates of Coverage: Retroactive Date:

 


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.

If you have had NO such claims/suits, indicate by checking this box.

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.

If NO, indicate by checking this box.

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.

PHYSICIAN WARRANTY

Warranty: It is warranted that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the Company evidence its acceptance of this application by issuance of a policy. I acknowledge and understand that any material misrepresentation or concealment of information requested by this application may be a basis for denial of a claim or voiding of coverage hereunder.

Authorization for Release of Information

By completing this application, I hereby consent to the release of information bearing on this application and hereby authorize USA Radiology Management Solutions, LLC to consult with administrators and members of the medical staff of hospitals or institutions with which I have been associated and with others, including past and present malpractice carriers, who may have information concerning my professional competence, character, and ethical qualifications. I hereby release from liability all representatives of USA Radiology Management Solutions, LLC for their acts performed in good faith and without malice concerning my professional competence, ethics, character and other qualifications for radiology duty. I fully understand that any significant misstatement in or omissions from this application constitute cause for termination of the independent-contractor status with USA Radiology Management Solutions, LLC. All information submitted by me in this application is true to my best knowledge and belief. A copy of this release shall be as valid as the original.

Name:*
I agree to the terms & conditions

USA Radiology Management Solutions, LLC

Please include current copies of the following documents with your completed application:

State Licenses*:
State Controlled Substance Certificates*:
Federal Narcotics License*:
Medical Diploma*:
ECFMG Certificate (If you are a foreign medical graduate)*:
Certificate of Internship and Residency*:
Curriculum Vitae*:
Recent Photograph (Passport size & not older than 6 months)*:
Medicare UPIN Number*:
Board Certification Certificate or Board Eligible Documentation*:
Drivers License*:
Social Security Card*:
Copy of letter assigning NPI number*:
TB/Chest X-ray completed within the last 12 months*:
Certificate of Insurance for past 10 years*:
Volume Report by Modality for past 2 years*:
CAQH Number, UserID, and Password (for billing purposes)*:

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