CREDENTIALING, NPDB, RELEASE AND AUTHORIZATION

All Information Must Be Complete

** We need DEA# and SS# to verify DEA. If info is missing, this form will not be processed. Our malpractice carrier requires this information. If anything is pending, please indicate pending **

Authorization Form

Authorization Form

Basic Information

All Information Must Be Complete

DEA Registration

(Medical, Tele, Locums, Controlled Substance, Training, Medical, Provisional, Temporary)

Active Licenses and Registrations

(Medical, Tele, Locums, Controlled Substance, Training, Medical, Provisional, Temporary)

Non-Active Licenses Only

(Expired, Lapsed, Superseded, Educational or any other)

Work Schedule

Licensure And Claims History

* If you answer "Yes"to any question, please provide a detailed explanation *

CV And Other Documents Upload

Declaration Of Health

I hereby declare that, to the best of my knowledge, I do not have a physical or mental condition that would adversely affect my ability to carry out the clinical privileges, which I have requested as a Locum Tenens physician.

Attestation, Authorization and Warranty

I authorize Locum Tenens USA, Inc. to release information to its Risk Management Department, insurance companies, and medical facility clients. I hereby authorize the disclosure by any institution (including but not limited to the Federation of State Medical Boards and State Licensing Boards) information regarding me, including my education, medical training and employment, skills, experience, fitness to practice medicine, character, work habits, job performance, certification, licensure, hospital staff or clinical privileges, DEA authorization and medical malpractice claims. The undersigned releases the above from any claims resulting from the disclosure of such opinions to LOCUM TENENS USA, Inc. I authorize the release of all information from Medical Schools, Colleges, Universities, Medical Institutions, Hospitals, Clinics, Physicians, State Medical Boards, Medical Malpractice Carriers, All Government Agencies, and any other source necessary to assist with my credentialing process. I understand that all information will be used to evaluate my professional qualifications, assist with credentialing at Health Care Facilities, and for use when applying to State Medical Boards for licensure are necessary.