Disclosure Questions - Please provide an explanation for any question answered yes in text box at the end of this form.
1) Has your license to practice, in your profession, ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation, or have you ever been subject to a consent order, probation or any conditions or limitations by any state licensing board?
2) Have you ever received a reprimand or been fined by any state licensing board?
Hospital Privileges and Other Affiliations
3) Have your clinical privileges or Medical Staff membership at any hospital or healthcare institution ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical records when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board?
4) Have you voluntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?
5) Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations such as IPAs, PHOs)?
Education, Training and Board Certification
6) Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education program? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign?
7) Have you ever, while under investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program?
8) Have any of your board certifications or eligibility ever been revoked?
9) Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation?
DEA or DPS
10) Have your Federal DEA and/or STATE Controlled Substances Certificate(s) or authorization(s) ever been denied, suspended, revoked, restricted, denied renewal, or voluntarily relinquished?
Medicare, Medicaid or other Governmental Program Participation
11) Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs?
Other Sanctions or Investigations
12) Are you currently or have you ever been the subject of an investigation by any hospital, licensing authority, DEA or DPS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program?
13) To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank?
14) Have you ever received sanctions from or been the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)?
15) Have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospital, facility, or agency, or voluntarily terminated or resigned while under investigation by a hospital or healthcare facility of any military agency?
Malpractice Claims History
16) Have you had any malpractice actions (pending, settled, arbitrated, mediated or litigated?
17) Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony or misdemeanor?
18) Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony or misdemeanor, involving an act of violence, child abuse or a sexual offense?
19) Have you been court-martialed for actions related to your duties as a medical professional?
Ability to Perform Job
20) Are you currently abusing alcohol, using any illegal drugs, or failing to take legally prescribed drugs in the manner prescribed?
21) Have you abused alcohol, used illegal drugs, or failed to take legally prescribed drugs in the manner prescribed in the past? If yes what drugs, and how recently have you used these illegal drugs?
22) Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety?
23) Do you have any reason to believe that you would pose a risk to the safety or well-being of your patients?
24) Are you unable to perform the essential functions of a practitioner in your area of practice, with or without reasonable accommodation?
Please use the space below to explain yes answers to any question.
I hereby affirm and acknowledge that the information provided by me on this pre-application and the attachments is true, complete and correct, and that Camden Healthcare Staffing, LLC and affiliates (The Companies), will rely on the truthfulness of my statements in evaluating my potential to be placed with The Companies' clients as a Locum Tenens provider or permanent associate. I hereby release Camden Healthcare Staffing, LLC it’s parent, subsidiaries, and affiliates, its officers, staff, representatives and agents from liability for their acts performed in good faith and without malice in connection with evaluating my application credentials and qualifications. I further release from liability provider, hospitals and other references for the good faith release of information regarding my professional capabilities and performances. I acknowledge that the decision to place me on the roster of eligible provider for placement as a Locum Tenens provider or permanent associate is solely at the discretion of The Companies. I further acknowledge that I will not circumvent The Companies and enter into an arrangement to provide temporary or permanent provider services with any individual, group or institution to which I am referred by The Companies, except through The Companies for a period of two years. I hereby release the above-named individuals and entities, including The Companies and all it’s affiliates, its officers, staff, representatives and agents from all liability for the release of information to a healthcare organization, or its agents, and agree and acknowledge that any and all individuals and organizations involved in the credentialing, application, and all aspects of the job search process, are entitled to absolute immunity from suit.
Candidate accepts and agrees that the specific identity (the actual name) of all hiring practices and all related jobs available is confidential information and is not to be disclosed to any third parties prior to accepting employment. The term "confidential" includes without limitations, all clients and available jobs learned through communications with AJ Riggins Health Search, Camden Healthcare Staffing or Camden Healthcare Government Staffing. As a candidate you agree to use independent judgment when accepting positions or interviews and therefore hold harmless, and grant absolute immunity from suit AJ Riggins Health Search, Camden Healthcare Staffing, Camden Healthcare Government Staffing, their officers, directors, employees and agents, from any and all liability, loss, damage or expense as a result of you accepting an associateship, partnership, locum tenens assignment, or ownership referred by AJ Riggins Health Search, Camden Healthcare Staffing, Camden Healthcare Government Staffing or any of their affiliates.
By clicking "Accept" I agree and understand that I am placing my electronic signature on this pre-application document, and therefore agreeing to all statements above.