If you are human, leave this field blank. Thank you for applying for reappointment. All questions must be answered. If you need more space to provide answers, please include your responses in the Additional Information section. If a question does not apply to you, please mark it as n/a. 1. IDENTIFYING INFORMATION First Name * Last Name * Middle Initial Social Security Number * Office Address * City * State * Zip * Phone (office) * Home Address * City * State * Zip * Phone (home) * Cell Phone * Email * Birthdate * Primary Specialty Secondary Specialty Status: MD DO DPM DDS Dentist PA F/NP RN LVN Pharmacist Dietician Dental Asst. Dental Hygienist Other: 2. LICENSURE CA License Number Date Issued Expiration Date DEA Number (if applicable) Date Issued Expiration Date 3. BOARD CERTIFICATION Are you board certified? Yes No Name of Board Date Cert/Recert Valid Through 4. HEALTH STATUSIf the answer is "NO" to either of the following questions, include details as an attachment. Are you able to perform all the services required with or without reasonable accomodation, according to accepted standards of professional performance and without posing a direct threat to the safety of patients? Yes No If "NO" or if reasonable accomodation is required, please explain in Additional Information section. Are you able to safely perform all the essential mental and physical functions related to the care of patients at the CVVIM Clinic? Yes No If "NO" or if reasonable accomodation is required, please explain in Additional Information section. 5. DISCIPLINARY and/or VOLUNTARY ACTIONSHave any of the following ever been, or are currently being, denied, revoked, suspended, relinquished, withdrawn, reduced, limited, placed on probation, not renewed, or currently under investigation? Clinical license in any jurisdiction? Yes No Other professional registration or license? Yes No DEA Certificate of registration or any applicable narcotic registration in any jurisdiction? Yes No Membership on any hospital medical staff? Yes No Clinical priviledges, prerogatives or rights on any medical staff? Yes No Board Certification? Yes No Any other type of professional sanction? Yes No Have you been subject to any disciplinary action in any health care organization, or is any such action pending? Yes No Have any special monitoring requirements been imposed? Yes No Have you resigned or taken a leave of absence in order to avoid possible revocation, suspension, or reduction of privileges at any hospital or institution? Yes No Have there been, or are there any, misdemeanor or felony criminal convictions against you, or charges pending against you, or have you ever taken "deferred adjucation" on any matter? Yes No Have you had any malpractice cases filed against you over the past five years? Yes No If "YES", please provide details in Attachment "A" Malpractice Claims Questionnaire. ATTACHMENT "A": MALPRACTICE CLAIM / SUIT QUESTIONNAIRE If you answered YES to Question 12 of DISCIPLINARY and/or VOLUNTARY ACTIONS of this application, please complete the following questionnaire for EACH CLAIM or SUIT. If you need to report more than one incident, please use the Additional Information field following the questionnaire. 1. The date the claim was made or suit was filed. If you do not recall the date, please state the year: 2. Date the alleged incident, which the subject of the claim or suit, occurred: 3. Name of the claimant or plaintiff: 4. Name of all defendants known to you: 5. Set forth a brief statement of the facts of the alleged incident and if the matter is pending, its current status: 6. If the alleged incident occurred in a hospital, name of the hospital: 7. If the matter has been concluded (whether by settlement, judgment or dismissal) state the method of conclusion and the date: 8. If the matter has been settled, state the total amount of the settlement and any contribution made by you or your insurance carrier to the settlement: 9. If the matter is concluded by judgement for the plaintiff, the amount of the total judgement and any amount against you if different: 10. Also state if the case was terminated by judgement in your favor or dismissal: ADDITIONAL INFORMATION Please enter any supplemental and/or explanatory information in the field below. REQUEST TO PROVIDE VOLUNTARY SERVICES By my signature below, I acknowledge that I have the burden of producing information requested by Coachella Valley Volunteers in Medicine for proper evaluation of my professional training, experience, competence, character, ethics and other qualifications and for resolving any doubts about such qualifications. I further acknowledge and agree that I will promptly and fully report all information to the CVVIM clinic in the event any of the answers above change, or if any situation arises which affects my ability to treat patients, after I have signed and dated this form. All the information contained in this application is complete and accurate to the best of my knowledge. I pledge that I am free from any chemical dependency and physically and mentally able to practice medicine and perform the volunteer services I have requested. I agree to abide by clinic policies and procedures as from time to time may be revised or enacted. CONSENT FOR RELEASE OF INFORMATION I hereby authorize Coachella Valley Volunteers in Medicine or their representatives, to consult with any entities or persons that may have information relative to my professional practice. A photocopy of this waiver shall be as effective as the original when so presented. This consent shall remain in full force and effect for a period of two (2) years from the date signed below. I hereby release from any liability all those who, in good faith, review, act on, or provide information regarding my competence, training, experience, professional ethics, character, health status, and other qualifications, for providing volunteer services. I understand that the completion of this application is my sole responsibility. I declare that the information furnished by me in this application is true and correct to the best of my knowledge. Your Name * Date * Confirm you're a real person.* Submit Edit