• E-mail
• Print
• RSS

Free form: Preapplication and reference form

Hospitalist Leadership Connection, November 17, 2010

As part of his or her preinterview assessments, the candidate should supply education and training references. The employer verifies the references to determine whether the candidate did in fact complete all the listed education. The employer should contact the listed universities and training programs to get primary source verification of these accomplishments. The candidate must provide written authorization for the contact person at each site. Use the below preapplication and reference form for each contact person.

Please answer the following questions by circling Y (Yes) or N (No).  If answering Yes to any questions below, please attach a written explanation (with the exception of questions 11 and 12). Remember to initial each answer.

1. Has your license to practice medicine in this state or any other state ever been denied, restricted, limited, suspended, or revoked?
    Y or N          Initials
2. Have you ever been reprimanded by a state-licensing agency, or are there any actions pending with respect to your license to practice medicine?
    Y or N          Initials
3. Have your hospital privileges ever been revoked, suspended, reduced, or not renewed, voluntarily or involuntarily, or have any disciplinary proceedings ever been instituted against you with respect to hospital privileges?
   Y or N          Initials        
4. While in residency or fellowship program, were you ever placed on probation or released involuntarily?         
   Y or N          Initials
5. Have you ever voluntarily relinquished hospital privileges, DEA (or state controlled substance registration), academic appointments, or any other profession status while an investigation was conducted?
   Y or N          Initials        
6. Has your DEA or state controlled substance registration ever been restricted, limited, suspended, or revoked, or are there any actions pending against you in regards to your DEA or other controlled substance registration?         
   Y or N          Initials
7. Has your participation in Medicare, Medicaid, or other government programs ever been denied, suspended, or revoked, or, to the best of your knowledge, have you ever been under investigation by a regulatory agency?     
   Y or N          Initials  
8. Has your professional liability insurance ever been canceled or has professional liability insurance application ever been denied?
   Y or N          Initials
9. Have you ever been convicted of a crime or do you have any felony or misdemeanor charges pending? 
   Y or N          Initials       
10. Have you ever been named in any professional malpractice suits or arbitrations over the past 10 years, which are either pending, or which went to final disposition or settlement and resulted in payment to the plaintiff?        Y or N     
    If yes, please list incident date, settlement date, professional liability insurer involved, number of defendants, allegations, and settlement amount.  Also please describe your role in the suit and the diagnosis, treatment, and patient outcome.  Please use additional sheets as necessary.        Initials
11. Are you legally eligible for permanent work in the United States?        
    Y or N    
    If not, please describe your current status. Initials
12. Are you board certified?       Y or N   
    If not, have you taken the boards and failed?       Y or N    Initials
    If you answered yes to the above question, how many times have you failed? Initials
    If you are not certified, when are you registered to take the exams?  Initials

To the best of my knowledge, the above information is true and accurate.

The above excerpt is adapted from Practical Guide to Hospitalist Recruitment and Retention, by Kirk Mathews, MBA, and John Nelson, MD, FACP, FHM, published by HCPro, Inc.

• E-mail to a Colleague
• Print
• RSS
• Archive