Healthcare Professional Credentialing Application Instructions

Check this box if, to your knowledge, information pertaining to you has been reported to the National Practitioner Data Bank or the Healthcare Integrity and Protection Data Bank.

Check this box if, to your knowledge, no information pertaining to you has ever been reported to the National Practitioner Data Bank or the Healthcare Integrity and Protection Data Bank.

Check this box if you have ever received sanctions from or been the subject of investigation by any regulatory agency (for example, CLIA, OSHA, etc.).

Check this box if you have never received sanctions from and have not been the subject of investigation by any regulatory agency.

Check this box if you have ever been investigated, sanctioned, reprimanded, cautioned by a military hospital/facility/agency, or voluntarily terminated/resigned while under investigation by a military healthcare facility or agency.

Check this box if you have never been investigated, sanctioned, reprimanded, cautioned by a military hospital/facility/agency, nor voluntarily terminated/resigned while under investigation by a military healthcare facility or agency.

Check this box if you have been convicted of, pled guilty to, or pled nolo contendere to any felony that is reasonably related to your qualifications, competence, functions, or duties as a medical professional.

Check this box if you have not been convicted of, pled guilty to, or pled nolo contendere to any felony that is reasonably related to your qualifications, competence, functions, or duties as a medical professional.

Check this box if you have been convicted of, pled guilty to, or pled nolo contendere to any felony including an act of violence, child abuse, or a sexual offense.

Check this box if you have not been convicted of, pled guilty to, or pled nolo contendere to any felony including an act of violence, child abuse, or a sexual offense.

Check this box if you have been court-martialed for actions related to your duties as a medical professional.

Check this box if you have not been court-martialed for actions related to your duties as a medical professional.

Check this box if you are currently engaged in the illegal use of drugs.

Check this box if you are not currently engaged in the illegal use of drugs.

Check this box if 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.

Check this box if you do not 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.

Check this box if you have any reason to believe that you would pose a risk to the safety or well‑being of your patients.

Check this box if you do not have any reason to believe that you would pose a risk to the safety or well‑being of your patients.

Check this box if you are unable to perform the essential functions of a practitioner in your area of practice with or without reasonable accommodation (i.e., your answer to question 23 is Yes).

Check this box if you are able to perform the essential functions of a practitioner in your area of practice with or without reasonable accommodation (i.e., your answer to question 23 is No).

Check this box if the practice location provides 24/7 phone coverage through an answering service.

Check this box if the practice location provides 24/7 phone coverage through voice mail, with instructions for the caller to contact an answering service.

Check this box if the practice location provides 24/7 phone coverage through voice mail, with other specific instructions for the caller.

Check this box if the practice location does not provide 24/7 phone coverage.

Check this box if the practice location provides 24/7 phone coverage through an answering service.

Check this box if the practice location provides 24/7 phone coverage via voice mail, instructing callers to contact an answering service.

Check this box if the practice location provides 24/7 phone coverage via voice mail with other specific instructions for callers.

Check this box if the practice location does not provide 24/7 phone coverage.

Check this box when the practice location conforms to ADA accessibility standards and is accessible as required.

Check this box when the practice location does not conform to ADA accessibility standards and is not fully accessible.

Check this box if you have additional current hospital affiliations and will complete and submit Attachment D with those affiliations.

Provide a detailed list of any additional office procedures offered, including surgical procedures.

Check this box if you received additional postgraduate training and need to complete and submit Attachment B.

Check this box to indicate that you have additional previous hospital affiliations and will complete and submit Attachment E.

Provide specific details regarding your additional specialty board status, particularly if you are not yet board certified. Fill only if 'Additional Specialty 2 - I am intending to sit for the Boards on (date)' is 'Yes'.

Check this box if you have already taken the specialty exam for Additional Specialty 2 and are awaiting official results from the certifying board. Fill only if 'Additional Specialty 1 - Board Certified? No' is 'Yes'. Fill only if 'Additional Specialty Certification: No' is 'Yes'.

Check this box if you have completed Part I of the specialty exam and are currently eligible to take Part II for Additional Specialty 2. Fill only if 'Additional Specialty 1 - Board Certified? No' is 'Yes'. Fill only if 'Additional Specialty Certification: No' is 'Yes'.

Check this box if you plan to sit for the certification boards for Additional Specialty 2 on a specific upcoming date (enter the date where indicated). Fill only if 'Additional Specialty 1 - Board Certified? No' is 'Yes'. Fill only if 'Additional Specialty Certification: No' is 'Yes'.

Check this box if you do not intend to pursue board certification for Additional Specialty 2. Fill only if 'Additional Specialty 1 - Board Certified? No' is 'Yes'. Fill only if 'Additional Specialty Certification: No' is 'Yes'.

Provide the name of the additional specialty.

Provide the name of the certifying board for this additional specialty. Fill only if 'Additional Specialty Certification: Yes' is 'Yes'.

Check this box if you are board certified for the additional specialty.

Check this box if you are not board certified for the additional specialty.

Enter the initial certification date for this additional specialty. Fill only if 'Additional Specialty Certification: Yes' is 'Yes'.

Enter the recertification date(s) if applicable for this additional specialty. Fill only if 'Additional Specialty Certification: Yes' is 'Yes'.

Enter the expiration date if applicable for this additional specialty. Fill only if 'Additional Specialty Certification: Yes' is 'Yes'.

Enter any other areas of professional practice interest or focus to be included in the directory listing.

Check this box if you wish to be listed in the directory under this specialty for HMO.

Check this box if you do not wish to be listed in the directory under this specialty for HMO.

Check this box if you wish to be listed in the directory under this specialty for PPO.

Check this box if you do not wish to be listed in the directory under this specialty for PPO.

Check this box if you wish to be listed in the directory under this specialty for POS.

Check this box if you do not wish to be listed in the directory under this specialty for POS.

Provide any necessary details or a reference for the submitted additional work history attachment.

Check this box if staff at this location have current Advanced Cardiac Life Support certification.

Check this box if providers at this location have current Advanced Cardiac Life Support certification that includes an expiration date.

Check this box if staff at this location have current Advanced Life Support in OB certification.

Check this box if the provider at this location has current Advanced Life Support in OB certification.

Check this box if staff at this location hold Advanced Trauma Life Support certification.

Check this box if a provider at this location has Advanced Trauma Life Support certification and experience.

Enter the classes or categories of anesthesia administered at this practice location. Fill only if 'Yes' is 'Yes'.

Check this box if anesthesia is administered at this practice location.

Check this box if anesthesia is not administered at this practice location.

Provide information on who administers anesthesia at this practice location. Fill only if 'Yes' is 'Yes'.

Provide the applicant's last name.

Provide the applicant's first name.

Provide the applicant's middle name.

Provide the applicant's name suffix, such as Jr. or Sr.

Enter the back office phone number for this practice location, including area code and extension if applicable.

Check this box if staff at this location have current Basic Life Support certification.

Check this box if a provider at this location has current Basic Life Support certification.

Enter the name of the billing company, if applicable.

Enter the name of the billing representative.

Enter the street address of the billing company.

Enter the city of the billing company.

Enter the state or country of the billing company.

Enter the postal code of the billing company.

Enter the phone number of the billing company.

Enter the fax number of the billing company.

Enter the e-mail address of the billing company.

Enter the name of the billing company, if applicable.

Enter the name of the billing representative.

Enter the street address for billing.

Enter the city for the billing address.

Enter the state or country for the billing address.

Enter the postal code for the billing address.

Enter the billing phone number.

Enter the billing fax number.

Enter the billing e-mail address.

Enter your date of birth as the date you were born.

Enter the city and state or country where you were born.

Enter your country of citizenship (include all citizenships if you hold more than one).

Check this box if you have not chosen not to re-certify and have not voluntarily surrendered your board certification(s) while under investigation.

Provide additional information if not board certified, such as the name of the board, exam name, or the date you intend to sit for the boards. Fill only if 'Intending to Sit for Boards' is 'Yes'.

Check this box if you have taken the board exam and are awaiting the results from the Board. Fill only if 'Secondary Specialty Board Certified' is 'No'.

Check this box if you have taken Part I of the board exam and are eligible for Part II of the Exam. Fill only if 'Secondary Specialty Board Certified' is 'No'.

Check this box if you are intending to sit for the board examination. Fill only if 'Secondary Specialty Board Certified' is 'No'.

Check this box if you are not planning to take the board examinations. Fill only if 'Secondary Specialty Board Certified' is 'No'.

Check this box if you have already taken the board examination and are currently awaiting the results from the Board. Fill only if 'Board Certified No' is 'No'.

Enter the name of the board for which you have taken the exam and are awaiting results. Fill only if '1st Option: Taken Exam, Results Pending' is 'Yes'.

Check this box if you have successfully completed Part I of the examination and are eligible for Part II. Fill only if 'Board Certified No' is 'No'.

Enter the name of the exam for which you have taken Part I and are eligible for Part II. Fill only if '2nd Option: Taken Part I, Eligible for Part II' is 'Yes'.

Check this box if you are planning to take the board examination and indicate the date you intend to sit for it. Fill only if 'Board Certified No' is 'No'.

Enter the date when you intend to sit for the board examination. Fill only if '3rd Option: Intending to Sit for Boards' is 'Yes'.

Check this box when you are attaching a list of hospital staff within your department that you utilize to provide call coverage.

Provide any additional information or confirmation regarding the attached list of hospital staff utilized for call coverage. Fill only if 'See attached list of hospital staff used for call coverage' is 'No'.

Check this box if staff at this location have Cardio-Pulmonary Resuscitation certification.

Check this box if the Cardio-Pulmonary Resuscitation certification for a provider at this location has an expiration date.

Check this box if this location provides childcare services.

Check this box if this location does not provide childcare services.

Check this box if none of your board certifications or eligibility have ever been revoked.

Check this box if you have ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations.

Check this box if you have never been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations.

Check this box if you have chosen not to re-certify or have voluntarily surrendered your board certification(s) while under investigation.

Enter the phone number for correspondence.

Enter the fax number.

Enter the email address.

Enter the street address for correspondence.

Enter the city for correspondence.

Enter the state or country for correspondence.

Enter the postal code for correspondence.

Enter the first line of the credentialing contact's street address.

Enter the second line of the credentialing contact's street address, if applicable.

Enter the city of the credentialing contact's address.

Enter the state or country of the credentialing contact's address.

Enter the postal code or ZIP code for the credentialing contact's address.

Enter the primary phone number for the credentialing contact.

Enter the fax number for the credentialing contact.

Enter the email address for the credentialing contact.

Please provide the first line of the credentialing contact's address. Fill only if 'CREDENTIALING CONTACT' is provided

Please provide the second line of the credentialing contact's address. Fill only if 'CREDENTIALING CONTACT' is provided

Please enter the city for the credentialing contact's address. Fill only if 'CREDENTIALING CONTACT' is provided

Please enter the state or country for the credentialing contact's address. Fill only if 'CREDENTIALING CONTACT' is provided

Please enter the postal code for the credentialing contact's address. Fill only if 'CREDENTIALING CONTACT' is provided

Please enter the phone number for the credentialing contact. Fill only if 'CREDENTIALING CONTACT' is provided

Please enter the fax number for the credentialing contact. Fill only if 'CREDENTIALING CONTACT' is provided

Please enter the email address for the credentialing contact. Fill only if 'CREDENTIALING CONTACT' is provided

Check this box if you are self-insured for malpractice coverage.

Check this box if you are not self-insured for malpractice coverage.

Please enter the name of your current malpractice insurance carrier or self-insured entity.

Please enter the first line of the address for your current malpractice insurance carrier or self-insured entity.

Please enter the city for your current malpractice insurance carrier or self-insured entity.

Please enter the state or country for your current malpractice insurance carrier or self-insured entity.

Please enter the postal code for your current malpractice insurance carrier or self-insured entity.

Please enter the phone number for your current malpractice insurance carrier or self-insured entity.

Please enter your current malpractice insurance policy number.

Please enter the effective date of your current malpractice insurance policy.

Please enter the expiration date of your current malpractice insurance policy.

Please enter the amount of malpractice insurance coverage per occurrence.

Please enter the aggregate amount of malpractice insurance coverage.

Check this box if your current malpractice insurance coverage is individual.

Check this box if your current malpractice insurance coverage is shared.

Please enter the length of time you have been with your current malpractice insurance carrier.

Check this box if you are currently practicing at this location. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Check this box if you are not currently practicing at this location. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Enter the date you expect to begin practicing at this location. Fill only if 'Currently Practicing at This Location — No' is 'Yes'. Fill only if 'Currently Practicing at This Location — No' is 'No'.

Please enter the name of your current practice or employer.

Please enter the start and end dates of your current practice or employer in MM/YYYY to MM/YYYY format.

Please enter the street address of your current practice or employer.

Please enter the city of your current practice or employer.

Please enter the state or country of your current practice or employer.

Please enter the postal code of your current practice or employer.

Enter the full DEA registration number (letters and/or digits) assigned to you for this DEA license.

Check this box if you have a DEA registration number and will provide that number in the adjacent DEA Number field.

Enter the original date when this DEA registration was issued.

Enter the date when this DEA registration expires.

Check this box if your Federal DEA and/or DPS Controlled Substances Certificate(s) or authorization(s) have ever been denied, suspended, revoked, restricted, denied renewal, or voluntarily relinquished.

Check this box if your Federal DEA and/or DPS Controlled Substances Certificate(s) or authorization(s) have never been denied, suspended, revoked, restricted, denied renewal, or voluntarily relinquished.

Enter the name of the department if the practice is hospital-based. Fill only if 'DO YOU HAVE HOSPITAL PRIVILEGES?' is 'Yes'.

Provide the name of the entity or individual to whom checks should be made payable.

Check this box if you want to be listed in the directory under this specialty for HMO.

Check this box if you do not want to be listed in the directory under this specialty for HMO.

Check this box if you want to be listed in the directory under this specialty for PPO.

Check this box if you do not want to be listed in the directory under this specialty for PPO.

Check this box if you want to be listed in the directory under this specialty for POS.

Check this box if you do not want to be listed in the directory under this specialty for POS.

Indicate your preference for being listed in the directory under this specialty, considering options such as HMO, PPO, and POS plans.

Please provide any additional notes or comments regarding your preferences for being listed in the directory under this specialty.

Check this box if you wish to be listed in the directory under this specialty for HMO.

Check this box if you do not wish to be listed in the directory under this specialty for HMO.

Check this box if you wish to be listed in the directory under this specialty for PPO.

Check this box if you do not wish to be listed in the directory under this specialty for PPO.

Check this box if you wish to be listed in the directory under this specialty for POS.

Check this box if you do not wish to be listed in the directory under this specialty for POS.

Check this box if you want this location to be listed in the directory.

Check this box if you do not want this practice location to be listed in the directory.

Check this box if you want this practice location to be listed in the directory.

Check this box if you do not want this practice location to be listed in the directory.

Enter your DPS registration or license number exactly as issued by the state DPS or licensing authority.

Check this box if you have a DPS registration number to report and will enter that number in the adjacent field.

Enter the date when the DPS registration or license was originally issued to you.

Enter the expiration date of your DPS registration or license.

Provide additional or alternative ECFMG number information if applicable. Fill only if 'American Citizen' is 'No'

Check this box if the Educational Council for Foreign Medical Graduates (ECFMG) information is not applicable to you. Fill only if 'American Citizen' is 'No'

Check this box if you are a foreign medical graduate and have ECFMG information. Fill only if 'American Citizen' is 'No'

Check this box if you are not a foreign medical graduate and do not have ECFMG information. Fill only if 'American Citizen' is 'No'

Enter your Educational Commission for Foreign Medical Graduates (ECFMG) number. Fill only if 'ECFMG 2 Yes' is 'Yes'.

Enter the date your ECFMG was issued. Fill only if 'ECFMG 2 Yes' is 'Yes'.

Check this box if you were ever placed on probation, disciplined, formally reprimanded, suspended, or asked to resign during an internship, residency, fellowship, preceptorship, or other clinical education program, or if you are currently in a training program and have been placed on probation, disciplined, formally reprimanded, suspended, or asked to resign.

Check this box if you have never been placed on probation, disciplined, formally reprimanded, suspended, or asked to resign during any internship, residency, fellowship, preceptorship, or other clinical education program and are not currently under such actions.

Check this box if you have ever, while under investigation, voluntarily withdrawn or been prematurely terminated from your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program.

Check this box if you have never, while under investigation, voluntarily withdrawn or been prematurely terminated from your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program.

Check this box if any of your board certifications or eligibility have ever been revoked.

Enter the number of the eighteenth disclosure question that requires an explanation. Fill only if 'a Disclosure Question' is 'Yes'.

Provide a detailed explanation for the answer given to the eighteenth disclosure question. Fill only if 'Eighteenth Disclosure Question Number' is a question number other than 16.

Enter the number of the eighth disclosure question for which an explanation is being provided. Fill only if 'a Disclosure Question' is 'Yes'.

Provide a detailed explanation for the eighth disclosure question. Fill only if 'Eighth Disclosure Question Number' is a question number other than 16.

Check this box if you are able to bill electronically.

Check this box if you are not able to bill electronically.

Check this box if you can bill electronically.

Check this box if you cannot bill electronically.

Enter the number of the disclosure question being explained in this eleventh entry. Fill only if 'a Disclosure Question' is 'Yes'.

Provide a detailed explanation for the 'yes' answer to the disclosure question identified in the eleventh 'Question Number' field. Fill only if 'Eleventh Disclosure Question Number' is a question number other than 16.

Enter the number of the disclosure question for which an explanation is being provided. Fill only if 'a Disclosure Question' is 'Yes'.

Provide a detailed explanation for the 'yes' answer to the specified disclosure question. Fill only if 'Fifteenth Disclosure Question Number' is a question number other than 16.

Enter the full name of the fifth colleague providing regular coverage.

Enter the specialty of the fifth colleague providing regular coverage.

Provide the question number for which the explanation is being provided. Fill only if 'a Disclosure Question' is 'Yes'.

Provide a detailed explanation for the 'yes' answer to the fifth disclosure question. Fill only if 'Fifth Disclosure Question Number' is a question number other than 16.

Enter the name of the other hospital where you have clinical privileges. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the date you began privileges at this hospital. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the hospital's street address (street number, suite, P.O. box if applicable). Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the city in which the hospital is located. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the state, province, or country where the hospital is located. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the ZIP or postal code for the hospital's address. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the hospital's primary telephone number, including area code as needed. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the hospital's fax number, including area code if applicable. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the hospital's primary contact e-mail address. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Check this box if you have full, unrestricted privileges at the fifth listed hospital. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Check this box if you do not have full, unrestricted privileges at the fifth listed hospital. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Describe the types of privileges you hold at this hospital (for example: provisional, limited, conditional, or specific clinical privileges). Fill only if 'Fifth Hospital - Full Unrestricted Privileges? No' is 'Yes'. Fill only if 'Fifth Hospital - Full Unrestricted Privileges? No' is 'Yes'.

Check this box if the privileges you hold at the fifth listed hospital are temporary. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Check this box if the privileges you hold at the fifth listed hospital are not temporary. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the percentage of your total admissions in the past year that were to this specific hospital. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Please provide the name of the institution that issued this professional degree. Fill only if 'Received other professional degrees' is 'Yes'.

Please provide the street address of the institution that issued this professional degree. Fill only if 'Fifth Other Professional Degree Issuing Institution' is filled.

Please provide the city where the institution that issued this professional degree is located. Fill only if 'Fifth Other Professional Degree Issuing Institution' is filled.

Please provide the state or country where the institution that issued this professional degree is located. Fill only if 'Fifth Other Professional Degree Issuing Institution' is filled.

Please provide the postal code for the institution that issued this professional degree. Fill only if 'Fifth Other Professional Degree Issuing Institution' is filled.

Please provide the full name of the professional degree obtained. Fill only if 'Fifth Other Professional Degree Issuing Institution' is filled.

Please provide the start and end dates of attendance for this professional degree in MM/YYYY format. Fill only if 'Fifth Other Professional Degree Issuing Institution' is filled.

Enter the specialty or area of training for the fifth post‑graduate program (for example: Internal Medicine, Pediatrics, etc.). Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Fifth Entry - Internship', 'Fifth Entry - Residency', 'Fifth Entry - Fellowship', 'Fifth Entry - Teaching Appointment' is checked, any.

Check this box if the fifth post-graduate education entry was an internship. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Check this box if the fifth post-graduate education entry was a residency. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Check this box if the fifth post-graduate education entry was a fellowship. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Check this box if the fifth post-graduate education entry was a teaching appointment. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the full name of the institution where you completed the fifth post‑graduate program. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the street address of the institution for the fifth program, including suite or department if applicable. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the city where the institution for the fifth program is located. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the state or country for the institution of the fifth program. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the postal code (ZIP or other postal code) for the institution of the fifth program. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Indicate whether the fifth program was successfully completed by entering 'Yes' or 'No'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Check this box if you successfully completed the program listed in the fifth post-graduate education entry. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the full name of the program director for the fifth post‑graduate program. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the full name of the current program director for the fifth program, if known; leave blank if unknown. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the full name of the previous hospital or facility where you held clinical privileges. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Enter the affiliation start and end dates for your privileges at this hospital. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Enter the hospital's street address, including suite or building number if applicable. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Enter the city where the hospital is located. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Enter the state, province, or country of the hospital's location. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Enter the postal code or ZIP code for the hospital's address. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Check this box if, for the hospital listed in Entry 5, you held full, unrestricted clinical privileges. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Check this box if, for the hospital listed in Entry 5, you did not hold full, unrestricted clinical privileges (your privileges were limited or restricted). Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

List the types of privileges you held at this hospital (for example provisional, limited, conditional, or full unrestricted). Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Entry 5 - Full Unrestricted Privileges? No' is 'No'.

Check this box if the privileges you held at the hospital in Entry 5 were temporary. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Check this box if the privileges you held at the hospital in Entry 5 were not temporary. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Provide the reason your privileges or affiliation with this hospital were discontinued or ended. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Enter the official name of the fifth previous practice or employer where you were employed. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'.

Enter the start and end dates for this period of employment with the fifth previous employer. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'Fifth Previous Employer — Employer Name' is filled.

Enter the full street address of the fifth previous employer, including suite or unit number if applicable. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'Fifth Previous Employer — Employer Name' is filled.

Enter the city where the fifth previous employer is located. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'Fifth Previous Employer — Employer Name' is filled.

Enter the state, province, or country for the location of the fifth previous employer. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'Fifth Previous Employer — Employer Name' is filled.

Enter the postal or ZIP code for the fifth previous employer's address (include letters if applicable). Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'Fifth Previous Employer — Employer Name' is filled.

Provide the reason this employment with the fifth previous employer ended (for example: resignation, termination, contract completion). Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'Fifth Previous Employer — Employer Name' is filled.

Enter the specialty of the first colleague.

Enter the number of the disclosure question you are explaining. Fill only if 'a Disclosure Question' is 'Yes'.

Provide a detailed explanation for the first disclosure question you are answering yes to. Fill only if 'First Disclosure Question Number' is a question number other than 16.

Enter the dates for the first gap in your work history. Fill only if 'Work History' has gaps greater than six months

Provide an explanation for the first gap in your work history. Fill only if 'Work History' has gaps greater than six months

Enter the full name of the other hospital where you currently have clinical privileges. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the date you began privileges at this hospital. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the hospital's street address, including suite or department if applicable. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the city in which the hospital is located. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the state or country where the hospital is located. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the hospital's postal or ZIP code. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the hospital's main telephone number, including area code and any extension if applicable. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the hospital's fax number, including area code. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter a primary email address for the hospital or department where you hold privileges. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Check this box if you currently have full, unrestricted clinical privileges at this hospital. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Check this box if you do not have full, unrestricted privileges at this hospital (your privileges are restricted or limited). Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Describe the types of privileges you hold at this hospital (for example: provisional, limited, conditional, full), listing specific privileges if applicable. Fill only if 'First Hospital — Full Unrestricted Privileges: No' is 'Yes'. Fill only if 'First Hospital — Full Unrestricted Privileges: No' is 'Yes'.

Check this box if your privileges at this hospital are temporary. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Check this box if your privileges at this hospital are not temporary (they are permanent or ongoing). Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the percentage of your total admissions in the past year that were to this specific hospital. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Provide the type of the first license being reported.

Enter the license number for the first license.

Specify the state where the first license is registered.

Enter the original date the first license was issued.

Enter the expiration date for the first license.

Check this box if you currently practice in the state for this first license.

Check this box if you do not currently practice in the state for this first license.

Enter the name of the institution that issued the first other professional degree. Fill only if 'Received other professional degrees' is 'Yes'.

Enter the street address of the institution for the first other professional degree. Fill only if 'First Issuing Institution' is filled.

Enter the city of the institution for the first other professional degree. Fill only if 'First Issuing Institution' is filled.

Enter the state or country of the institution for the first other professional degree. Fill only if 'First Issuing Institution' is filled.

Enter the postal code of the institution for the first other professional degree. Fill only if 'First Issuing Institution' is filled.

Enter the name of the first other professional degree obtained. Fill only if 'First Issuing Institution' is filled.

Enter the start and end dates of attendance for the first other professional degree. Fill only if 'First Issuing Institution' is filled.

Check this box if you have additional work history not listed on the form; doing so indicates you will complete and submit Attachment C with those additional details.

Enter the full name and title of the first peer reference.

Enter the phone number for the first peer reference.

Enter the street address for the first peer reference.

Enter the city for the first peer reference.

Enter the state or country for the first peer reference.

Enter the postal code for the first peer reference.

Enter the specialty or discipline for this post-graduate training (for example, Internal Medicine, Surgery, Pediatrics, etc.). Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes' in any fields selection. Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes', any.

Check this box when the post‑graduate training entry you are providing for the institution is an Internship.

Check this box when the post‑graduate training entry you are providing for the institution is a Residency.

Check this box when the post‑graduate training entry you are providing for the institution is a Fellowship.

Check this box when the post‑graduate entry you are providing for the institution is a Teaching Appointment.

Enter the full name of the post‑graduate institution where the program was completed. Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes' in any fields selection. Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes', any.

Enter the street address of the institution, including suite or building number if applicable. Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes' in any fields selection. Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes', any.

Enter the city in which the institution is located. Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes' in any fields selection. Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes', any.

Enter the state, province, or country where the institution is located. Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes' in any fields selection. Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes', any.

Enter the institution's postal code or ZIP code. Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes' in any fields selection. Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes', any.

If the program was completed, enter the completion date (month and year) or a brief note indicating completion; leave blank if not completed. Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes' in any fields selection. Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes', any.

Check this box if you successfully completed the listed Post-Graduate Program 1 (mark only if the program was completed).

Enter the program attendance start and end dates (for example, MM/YYYY to MM/YYYY). Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes' in any fields selection. Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes', any.

Enter the full name of the program director who supervised the program you attended. Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes' in any fields selection. Fill only if 'Post-Graduate Program 1: Completion' is 'Yes'.

Enter the full name of the program's current director if known, otherwise leave blank. Fill only if 'Internship', 'Residency', 'Fellowship', 'Teaching Appointment' is 'Yes' in any fields selection. Fill only if 'Post-Graduate Program 1: Completion' is 'No'.

Enter the specialty or field of training for this post-graduate education entry. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Other Post-Graduate Education (First) - Internship', 'Other Post-Graduate Education (First) - Residency', 'Other Post-Graduate Education (First) - Fellowship', 'Other Post-Graduate Education (First) - Teaching Appointment' is checked, any.

Check this box if the first listed other post-graduate education entry was an internship program. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Check this box if the first listed other post-graduate education entry was a residency program. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Check this box if the first listed other post-graduate education entry was a fellowship program. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Check this box if the first listed other post-graduate education entry was a teaching appointment. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the full name of the institution where this post‑graduate education was completed or attended. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the institution's street address, suite or building information for this entry. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the city of the institution where this post‑graduate education took place. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the state or country of the institution for this post‑graduate education entry. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the postal or ZIP code for the institution's address. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Provide any notes about program completion (for example, completion status, completion date, or brief explanation) for this entry. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Check this box if you successfully completed the program listed for this first other post-graduate education entry. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the attendance end date for this post‑graduate program. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the attendance start date for this post‑graduate program. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the full name of the program director responsible for this post‑graduate program. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

If known, enter the specialty or department of the current program director for this program. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

If known, enter the full name of the current program director for this program. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the provider's full name, professional designation (for example MD, RN, PA), and the state plus license number (e.g., CA 123456) separated by commas or spaces as appropriate. Fill only if 'DO NURSE PRACTITIONERS, PHYSICIAN ASSISTANTS, MIDWIVES, SOCIAL WORKERS OR OTHER NON-PHYSICIAN PROVIDERS CARE FOR PATIENTS AT THIS PRACTICE LOCATION?' is 'Yes'. Fill only if 'DO NURSE PRACTITIONERS, PHYSICIAN ASSISTANTS, MIDWIVES, SOCIAL WORKERS OR OTHER NON-PHYSICIAN PROVIDERS CARE FOR PATIENTS AT THIS PRACTICE LOCATION?' is 'Yes'.

Enter the full name of the previous practice or employer for this row.

Enter the start and end dates for your employment with this previous practice/employer.

Enter the street address (including building number, street name, and suite or floor if applicable) of the previous practice/employer.

Enter the city where the previous practice/employer was located.

Enter the state, province or country for the previous practice/employer's location.

Enter the postal or ZIP code for the previous practice/employer's address.

Provide a brief explanation of why you left or discontinued employment at this previous practice/employer.

Enter the name of the first previous hospital where you had privileges.

Enter the affiliation dates for the first previous hospital, including both start and end dates.

Enter the street address of the first previous hospital.

Enter the city of the first previous hospital.

Enter the state or country of the first previous hospital.

Enter the postal code of the first previous hospital.

Check this box if, at the previous hospital listed in Entry 1, you were granted full, unrestricted clinical privileges. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Check this box if, at the previous hospital listed in Entry 1, your privileges were not full and unrestricted (for example provisional, limited, conditional, etc.). Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Enter the types of privileges held at the first previous hospital, such as provisional, limited, or conditional. Fill only if 'Entry 1 - Full Unrestricted Privileges: No' is 'No'.

Check this box if the privileges you held at the previous hospital in Entry 1 were temporary in nature. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Check this box if the privileges you held at the previous hospital in Entry 1 were not temporary (i.e., they were ongoing or permanent during that affiliation). Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Enter the reason for discontinuing privileges at the first previous hospital.

Enter the full name of the first previous practice or employer. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'.

Enter the start and end dates for your employment at this practice or employer. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'First Previous Practice/Employer Name' is filled.

Enter the street address of the first previous practice or employer, including apartment or suite number if applicable. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'First Previous Practice/Employer Name' is filled.

Enter the city where the first previous practice or employer is located. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'First Previous Practice/Employer Name' is filled.

Enter the state or country for the first previous practice or employer's address. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'First Previous Practice/Employer Name' is filled.

Enter the postal or ZIP code for the first previous practice or employer's address. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'First Previous Practice/Employer Name' is filled.

Provide the reason you discontinued employment with the first previous practice or employer. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'First Previous Practice/Employer Name' is filled.

Please enter the full name and title of the first reference.

Please provide the phone number for the first reference.

Please enter the complete street address for the first reference.

Please enter the city of the first reference.

Please provide the state or country of the first reference.

Please enter the postal code for the first reference's address.

Please provide the full name of the first staff member. Fill only if 'Yes' is 'Yes'.

Please provide the professional designation of the first staff member. Fill only if 'Yes' is 'Yes'.

Please provide the state and license number of the first staff member. Fill only if 'Yes' is 'Yes'.

Enter the full name of the first staff member. Fill only if 'Yes' is 'Yes'.

Enter the professional designation or title of the first staff member. Fill only if 'Yes' is 'Yes'.

Enter the state and license number for the first staff member. Fill only if 'Yes' is 'Yes'.

Enter the start and end dates for the first employment gap shown.

Enter the start date for the second employment gap.

Provide a brief explanation describing the reason for the first employment gap lasting more than six months. Fill only if 'Gap 1 Dates' indicates a gap greater than six months.

Provide the number of the fourteenth disclosure question that requires an explanation. Fill only if 'a Disclosure Question' is 'Yes'.

Provide a detailed explanation for the 'yes' answer to the fourteenth disclosure question. Fill only if 'Fourteenth Disclosure Question Number' is a question number other than 16.

Please provide the name of the fourth colleague providing regular coverage.

Please provide the specialty of the fourth colleague providing regular coverage.

Enter the number of the fourth disclosure question for which you are providing an explanation. Fill only if 'a Disclosure Question' is 'Yes'.

Provide the explanation for your 'yes' answer to the fourth disclosure question. Fill only if 'Fourth Question Number' is a question number other than 16.

Enter the name of the other hospital where you have clinical privileges. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Provide the date when your privileges at this hospital began. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the street address of the hospital, including suite or floor if applicable. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the city where the hospital is located. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the state, province, or country of the hospital. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the postal or ZIP code for the hospital's address. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the hospital's main telephone number, including country and area code if applicable. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the hospital's fax number for credentialing or administrative contacts. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the primary email address to contact the hospital's credentialing or administrative office. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Check this box if, for the fourth listed hospital affiliation, you have full, unrestricted clinical privileges. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Check this box if, for the fourth listed hospital affiliation, you do not have full, unrestricted clinical privileges. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Describe the types of privileges you hold at this hospital (for example: provisional, limited, conditional, full, etc.). Fill only if 'Fourth Hospital — Full Unrestricted Privileges? No' is 'Yes'. Fill only if 'Fourth Hospital — Full Unrestricted Privileges? No' is 'Yes'.

Check this box if the privileges at the fourth listed hospital are temporary. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Check this box if the privileges at the fourth listed hospital are not temporary (i.e., ongoing or permanent). Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the percentage of your total admissions in the past year that were to this specific hospital. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Please enter the name of the institution that issued the fourth professional degree. Fill only if 'Received other professional degrees' is 'Yes'.

Please provide the street address for the institution that issued the fourth professional degree. Fill only if 'Fourth Professional Degree Issuing Institution' is filled.

Please enter the city where the institution that issued the fourth professional degree is located. Fill only if 'Fourth Professional Degree Issuing Institution' is filled.

Please enter the state or country where the institution that issued the fourth professional degree is located. Fill only if 'Fourth Professional Degree Issuing Institution' is filled.

Please enter the postal code for the institution that issued the fourth professional degree. Fill only if 'Fourth Professional Degree Issuing Institution' is filled.

Please enter the name of the fourth professional degree obtained. Fill only if 'Fourth Professional Degree Issuing Institution' is filled.

Please enter the start and end dates of attendance for the fourth professional degree in MM/YYYY to MM/YYYY format. Fill only if 'Fourth Professional Degree Issuing Institution' is filled.

Enter the specialty or field of study for this post-graduate program. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Fourth - Internship', 'Fourth - Residency', 'Fourth - Fellowship', 'Fourth - Teaching Appointment' is checked, any.

Check this box if the fourth post-graduate education entry was an Internship. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Check this box if the fourth post-graduate education entry was a Residency. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Check this box if the fourth post-graduate education entry was a Fellowship. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Check this box if the fourth post-graduate education entry was a Teaching Appointment. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the full name of the institution where this post‑graduate training took place. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the street address (building, street, or P.O. box) for the institution. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the city in which the institution is located. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the state or country in which the institution is located. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the postal code or ZIP code for the institution's address. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the indication of whether the program was successfully completed (for example, 'Yes' or 'No'). Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Check this box if you successfully completed the fourth post-graduate education program. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the attendance dates for this program (start and end). Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the name of the program director for this training program. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the name of the current program director, if known. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter additional short identifying information for the current program director such as professional credentials or title (e.g., MD, PhD). Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment B if you received additional postgraduate training.' is 'Yes'.

Enter the provider's full name followed by their professional designation and the state and license number (for example: Jane Doe, MD, CA LIC #123456); separate each element by commas or spaces as needed. Fill only if 'DO NURSE PRACTITIONERS, PHYSICIAN ASSISTANTS, MIDWIVES, SOCIAL WORKERS OR OTHER NON-PHYSICIAN PROVIDERS CARE FOR PATIENTS AT THIS PRACTICE LOCATION?' is 'Yes'. Fill only if 'DO NURSE PRACTITIONERS, PHYSICIAN ASSISTANTS, MIDWIVES, SOCIAL WORKERS OR OTHER NON-PHYSICIAN PROVIDERS CARE FOR PATIENTS AT THIS PRACTICE LOCATION?' is 'Yes'.

Enter the full name of the previous hospital or healthcare facility where you had privileges. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Enter the start and end affiliation dates for your privileges at this hospital. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Enter the hospital's street address (including building, suite, or PO box as appropriate). Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Enter the city in which the hospital is located. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Enter the state or country (as appropriate) where the hospital is located. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Enter the postal or ZIP code for the hospital's address. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Check this box if at the listed hospital (Entry 4) you were granted full, unrestricted clinical privileges. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Check this box if at the listed hospital (Entry 4) you did not have full, unrestricted privileges (for example, you held provisional, limited, or conditional privileges). Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

List the types of privileges you were granted at that hospital (for example provisional, limited, conditional). Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Entry 4 - Full Unrestricted Privileges? No' is 'No'.

Check this box if the privileges you held at the listed hospital (Entry 4) were temporary in nature. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Check this box if the privileges you held at the listed hospital (Entry 4) were not temporary (i.e., were ongoing or permanent during your affiliation). Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Provide the reason why your privileges at this hospital were discontinued or ended. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.' is 'Yes'.

Provide the full name of the fourth previous practice or employer (organization or individual) as it appears on records. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'.

Enter the start and end dates for your employment or affiliation with this fourth previous practice/employer. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'Fourth Previous Employer Name' is filled.

Enter the full street address of the fourth previous practice/employer, including suite or unit number if applicable. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'Fourth Previous Employer Name' is filled.

Enter the city where the fourth previous practice/employer is located. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'Fourth Previous Employer Name' is filled.

Enter the state (or province) abbreviation or the country name for the fourth previous practice/employer. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'Fourth Previous Employer Name' is filled.

Enter the postal or ZIP code for the fourth previous practice/employer. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'Fourth Previous Employer Name' is filled.

Briefly describe the reason your employment or affiliation with the fourth previous practice/employer ended. Fill only if 'Please check this box and complete and submit Attachment C if you have additional work history' is 'Yes'. Fill only if 'Fourth Previous Employer Name' is filled.

Check this box if patients are not seen during office hours on Friday.

Enter the start time for office hours on Friday mornings.

Enter the end time for office hours on Friday mornings. Fill only if 'Friday No Office Hours' is 'No'.

Enter the complete office hours for Friday afternoons. Fill only if 'Friday No Office Hours' is 'No'.

Enter the complete office hours for Friday evenings. Fill only if 'Friday No Office Hours' is 'No'.

Check this box if there are no office hours for patients on Friday.

Please enter the start time for patient hours on Friday morning. Fill only if 'Friday No Office Hours' is 'No'.

Please enter the end time for patient hours on Friday morning. Fill only if 'Friday No Office Hours' is 'No'.

Please enter the start time for patient hours on Friday afternoon. Fill only if 'Friday No Office Hours' is 'No'.

Please enter the start time for patient hours on Friday evening. Fill only if 'Friday No Office Hours' is 'No'.

Provide the group number that corresponds to the Tax ID/EIN used by your organization for billing or administrative purposes.

Enter the official group or practice name that is associated with the Tax ID/EIN entered above.

Check this box if the building itself is handicapped accessible (e.g., accessible entrances, ramps, elevators). Fill only if 'Does this practice location meet ADA accessibility standards? — Yes' is 'Yes'.

Check this box if parking areas include handicapped-accessible parking spaces and accessible routes to the building. Fill only if 'Does this practice location meet ADA accessibility standards? — Yes' is 'Yes'.

Check this box if restrooms are handicapped accessible (e.g., accessible stalls, grab bars, appropriate fixtures and clearances). Fill only if 'Does this practice location meet ADA accessibility standards? — Yes' is 'Yes'.

Check this box if other facility features are handicapped accessible, and describe those features in the provided 'Other' specification field. Fill only if 'Does this practice location meet ADA accessibility standards? — Yes' is 'Yes'.

Enter a short description naming any other handicapped accessible facility at this location that is not listed (e.g., ramped entrance, elevator, tactile signage). Fill only if 'Other (specify)' is 'Yes'. Fill only if 'Other (specify)' is 'Yes'.

Please provide your home mailing street address.

Please provide the city for your home mailing address.

Please provide the state or country for your home mailing address.

Please provide the postal code for your home mailing address.

Check this box if your clinical privileges or Medical Staff membership at any hospital or healthcare institution has ever been denied, suspended, revoked, restricted, denied renewal, or been subject to probationary or other disciplinary conditions, or if proceedings toward any of those ends have been instituted or recommended. Fill only if 'DO YOU HAVE HOSPITAL PRIVILEGES?' is 'Yes'.

Check this box if your clinical privileges or Medical Staff membership at any hospital or healthcare institution has NOT been denied, suspended, revoked, restricted, denied renewal, or been subject to probationary or other disciplinary conditions, and if no such proceedings have been instituted or recommended. Fill only if 'DO YOU HAVE HOSPITAL PRIVILEGES?' is 'Yes'.

Check this box if you currently have hospital privileges.

Check this box if you do not currently have hospital privileges.

Please provide details of your admitting arrangements if you do not have admitting privileges. Fill only if 'Hospital Privileges No' is 'No'.

Enter the Medicaid identification number assigned specifically to this practice site.

Enter the employer tax identification number (EIN) associated with this practice or group.

If interpreters are available at this practice location, enter the languages they can interpret (e.g., Spanish, Mandarin, American Sign Language), separated by commas; leave blank if none. Fill only if 'Interpreters Available — Yes' is 'Yes'. Fill only if 'Interpreters Available — Yes' is 'Yes'.

Check this box if interpreters are available at this practice location (and, if checked, list the languages in the adjacent 'If yes, please specify languages' field).

Check this box if interpreters are not available at this practice location.

Check this box if you are attaching a separate list of all partners in your practice because it is a large group.

Check this box if your license to practice has ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation, or if you have ever been subject to a consent order, probation, or any conditions or limitations by any state licensing board.

Check this box if your license to practice has never been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation, and you have never been subject to a consent order, probation, or any conditions or limitations by any state licensing board.

Check this box if you have ever received a reprimand or been fined by any state licensing board.

Check this box if you have never received a reprimand or been fined by any state licensing board.

Enter the applicant's maiden name.

Enter the years during which the applicant was associated with their maiden name in YYYY-YYYY format.

Check this box if you have had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated).

Check this box if you answered 'Yes' to malpractice actions and have completed and submitted Attachment G. Fill only if 'Malpractice Claims History Yes' is 'Yes'.

Check this box if you have not had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated).

Check this box if you have been terminated for cause, not renewed for cause from participation, or subjected to any disciplinary action by any managed care organization.

Enter the Medicaid provider number assigned to you by the state Medicaid program exactly as issued; leave blank if you are not a participating Medicaid provider. Fill only if 'Medicaid participating provider — Yes' is 'Yes'. Fill only if 'Medicaid Provider Yes' is 'Yes'.

Check this box if you are a participating Medicaid provider.

Check this box if you are not a participating Medicaid provider.

Enter the Medicare provider number assigned to you by Medicare (the alphanumeric identifier used for billing) if you are a participating Medicare provider; leave blank if not applicable. Fill only if 'Participating Medicare Provider — Yes' is 'Yes'. Fill only if 'Participating Medicare Provider — Yes' is 'Yes'.

Check this box if you are currently a participating Medicare provider (and provide your Medicare Provider Number in the adjacent field).

Check this box if you are not currently a participating Medicare provider.

Check this box if you have never 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.

Check this box if you have 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.

Check this box if you have U.S. military service or public health experience.

Check this box if you do not have U.S. military service or public health experience.

Enter the end date of your military service. Fill only if 'US Military Service Yes' is 'Yes'.

Provide the last location where you served in the military. Fill only if 'US Military Service Yes' is 'Yes'.

Enter the specific branch of the military in which you served. Fill only if 'US Military Service Yes' is 'Yes'.

If you are currently on active or reserve military duty, provide your current status, unit/assignment or other relevant details; leave blank if not currently serving. Fill only if 'US Military Service Yes' is 'Yes'.

Check this box if you are currently on active or reserve military duty.

Check this box if you are not currently on active or reserve military duty.

Check this box if the practice location qualifies as a Minority Business Enterprise.

Check this box if the practice location does not qualify as a Minority Business Enterprise.

Enter the closing time for Monday afternoon patient appointments. Fill only if 'Monday No Office Hours' is 'No'.

Enter the closing time for Monday evening patient appointments. Fill only if 'Monday No Office Hours' is 'No'.

Check this box if there are no patient office hours on Monday.

Please enter the end time for Monday morning office hours. Fill only if 'Monday No Office Hours' is 'No'.

Please enter the office hours for Monday afternoon. Fill only if 'Monday No Office Hours' is 'No'.

Please enter the office hours for Monday evening. Fill only if 'Monday No Office Hours' is 'No'.

Please enter the start time for Monday morning office hours.

Check this box if there are no patient office hours on Monday.

Enter the start time for patient hours on Monday mornings. Fill only if 'Monday No Office Hours' is 'No'.

Enter the end time for patient hours on Monday mornings. Fill only if 'Monday No Office Hours' is 'No'.

Check this box if this practice location currently has staff members who hold Neonatal Advanced Life Support certification.

Check this box if a provider at this location has Neonatal Advanced Life Support certification and its expiration date is being provided.

Provide an explanation if new patient acceptance policies vary based on the health plan. Fill only if 'All New Patients', 'Existing Patients with Change of Payor', 'New Patients with Referral', 'New Medicare Patients', 'New Medicaid Patients' new patient acceptance varies by health plan.

Enter the number of the nineteenth disclosure question that requires an explanation. Fill only if 'a Disclosure Question' is 'Yes'.

Provide a detailed explanation for the 'yes' answer given to the nineteenth disclosure question. Fill only if 'Nineteenth Disclosure Question Number' is a question number other than 16.

Enter the number of the disclosure question that requires an explanation. Fill only if 'a Disclosure Question' is 'Yes'.

Provide a detailed explanation for the 'yes' answer to the specified disclosure question. Fill only if 'Ninth Disclosure Question Number' is a question number other than 16.

Check this box if nurse practitioners, physician assistants, midwives, social workers, or other non-physician providers care for patients at this practice location. Fill only if 'have other practice locations' is 'Yes'.

Check this box if nurse practitioners, physician assistants, midwives, social workers, or other non-physician providers do not care for patients at this practice location. Fill only if 'have other practice locations' is 'Yes'.

Check this box if nurse practitioners, physician assistants, midwives, social workers, or other non-physician providers care for patients at this practice location.

Check this box if nurse practitioners, physician assistants, midwives, social workers, or other non-physician providers do not care for patients at this practice location.

Enter the full name of the office manager or staff contact.

Enter the phone number for the office manager or staff contact.

Enter the fax number for the office manager or staff contact.

Enter the full name of the office manager or primary staff contact for this practice location (first and last name, and title if desired). Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Enter the office or direct phone number where the office manager or staff contact can be reached during business hours. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Enter the practice location's fax number associated with the office manager or staff contact. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Check this box if this practice location provides one or more services on-site (i.e., any of the listed services are available at this location).

Check this box if this practice location does not provide any of the listed services on-site.

Check this box if the location provides on-site Laboratory Services.

Provide a list of all Certificates of Participation for on-site laboratory services, including CLIA, AAFP, COLA, CAP, and MLE.

Check this box if this location provides one or more of the listed on-site services (i.e., any of the services referenced in this section).

Check this box if this location does not provide any of the listed on-site services.

Provide a list of all certifications for on-site X-ray services. Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the practice location provides on-site X-ray services.

Enter the name or type of the other CDS registration or certificate you are reporting.

Enter the registration or license number assigned to this CDS registration exactly as it appears on the document.

Enter the U.S. state or other issuing jurisdiction where this CDS registration was issued.

Enter the date the CDS registration was originally issued.

Enter the date the CDS registration is set to expire.

Check this box if, for the Other CDS registration listed on this row, you currently practice in the state shown (i.e., you actively practice in that state).

Check this box if, for the Other CDS registration listed on this row, you do NOT currently practice in the state shown (i.e., you are not actively practicing in that state).

Check this box if staff at this location possess other current certifications not explicitly listed on the form.

Check this box if a provider at this location possesses other current certifications not explicitly listed on the form.

Provide a list of all Certificates of Participation for laboratory services, including examples such as CLIA, AAFP, COLA, CAP, and MLE. Fill only if 'Provides Any On-site Services: Yes' is 'Yes'.

Enter the name of the institution that issued the graduate-level education. Fill only if 'Received other professional degrees' is 'Yes'

Enter the street address of the issuing institution. Fill only if 'Received other professional degrees' is 'Yes'

Enter the city of the issuing institution. Fill only if 'Received other professional degrees' is 'Yes'

Enter the state or country of the issuing institution. Fill only if 'Received other professional degrees' is 'Yes'

Enter the postal code for the issuing institution. Fill only if 'Received other professional degrees' is 'Yes'

Enter the degree awarded for the graduate-level education. Fill only if 'Received other professional degrees' is 'Yes'

Enter the start and end dates of attendance for the graduate-level education. Fill only if 'Received other professional degrees' is 'Yes'

Please provide the name of the other hospital where you have privileges. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Please enter the start date of your privileges at this other hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Please provide the street address of the other hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Please enter the city of the other hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Please provide the state or country of the other hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Please enter the postal code of the other hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Please provide the phone number of the other hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Please provide the fax number of the other hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Please provide the email address of the other hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Check this box if you have full unrestricted privileges at the other hospital listed. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Check this box if you do not have full unrestricted privileges at the other hospital listed. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Please specify the types of privileges you have at this other hospital, such as provisional, limited, or conditional. Fill only if 'Other Hospital - Full Unrestricted Privileges? No' is 'No'.

Check this box if your privileges at the other hospital listed are temporary. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Check this box if your privileges at the other hospital listed are not temporary. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Please provide the percentage of your total admissions to all hospitals in the past year that were to this specific other hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Provide any other name used.

Enter the years associated with the other name, in YYYY-YYYY format.

Provide detailed information regarding any additional practice locations, as requested in relation to Attachment F.

Check this box if you have other practice locations and need to complete and submit Attachment F.

Check this box if you have received any other professional degrees and you will complete and submit Attachment A with details about those additional degrees.

Enter any other areas of professional practice interest or focus, including but not limited to HIV/AIDS.

Check this box if you currently are or have ever been the subject of an investigation by any hospital, licensing authority, DEA or DPS, an education or training program, Medicare/Medicaid program, or any other private, federal, or state health program.

Check this box if you have never been and are not currently the subject of any investigation by a hospital, licensing authority, DEA or DPS, an education or training program, Medicare/Medicaid, or any other private, federal, or state health program.

Please list all certifications for X-ray services provided as an other service.

Check this box if the location provides radiology services on site (e.g., X-ray, imaging). Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the location performs electrocardiograms (EKG) on site. Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the location treats minor cuts and lacerations on site. Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the location performs pulmonary function tests (PFTs) on site. Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the location provides allergy injection (immunotherapy) services. Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the location performs allergy skin testing. Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the location offers routine gynecological office services. Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the location provides blood draw/phlebotomy services on site. Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the location administers age-appropriate immunizations (vaccines). Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the location performs flexible sigmoidoscopy procedures. Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the location performs tympanometry or audiometry hearing tests. Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the location provides treatments or management services for asthma. Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the location offers osteopathic manipulation treatments. Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the location provides IV hydration or other intravenous treatments on site. Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the location performs cardiac stress testing. Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the location offers physical therapy services. Fill only if 'Other On-site Services — Yes' is 'Yes'.

Check this box if the location provides other services not listed and specify what those services are. Fill only if 'Other On-site Services — Yes' is 'Yes'.

Specify any other services for the disabled provided by this location that are not listed. Fill only if 'Other Services' is 'Yes'.

Check this box if the location provides Text Telephony-TTY services for the disabled.

Check this box if the location provides American Sign Language (ASL) services for the disabled.

Check this box if the location provides services for individuals with mental or physical impairments.

Check this box if the location provides other services for the disabled not listed above, and then specify them.

Provide the name(s) of the managed care company(s) or hospital(s) to which you are applying.

Enter the name for the first entry.

Enter the name for the second entry.

Enter the name for the third entry.

Enter the name for the fourth entry.

List the non-English languages spoken by health care providers at this location.

List the non-English languages spoken by office personnel at this location.

Check this box if interpreters are available at this practice location.

Check this box if interpreters are not available at this practice location.

If interpreters are available, specify the languages they speak.

Check this box if this practice location meets ADA accessibility standards.

Check this box if this practice location does not meet ADA accessibility standards.

Check this box if the building at this practice location is handicapped accessible.

Check this box if parking at this practice location is handicapped accessible.

Check this box if restrooms at this practice location are handicapped accessible.

Check this box if other facilities not listed are handicapped accessible.

If other facilities are handicapped accessible beyond those listed, please specify them.

If other services are available for the disabled beyond those listed, please specify them.

Check this box if the location provides Text Telephony-TTY services for the disabled.

Check this box if the location provides American Sign Language (ASL) services for the disabled.

Check this box if the location provides mental or physical impairment services for the disabled.

Check this box if the location provides other services for the disabled not listed.

If accessible by other public transportation methods beyond those listed, please specify them.

Check this box if this location is accessible by bus.

Check this box if this location is accessible by regional train.

Check this box if this location is accessible by other forms of public transportation not listed.

List the applicant's current certification expiration dates for the certifications listed.

Check this box if this location provides childcare services.

Check this box if this location does not provide childcare services.

Check this box if this location qualifies as a minority business enterprise.

Check this box if this location does not qualify as a minority business enterprise.

Check this box if staff at this location have Basic Life Support certification.

Check this box if a provider at this location has Basic Life Support certification.

Check this box if staff at this location have Advanced Life Support in OB certification.

Check this box if a provider at this location has Advanced Life Support in OB certification.

Check this box if staff at this location have Advanced Trauma Life Support certification.

Check this box if a provider at this location has Advanced Trauma Life Support certification.

Check this box if staff at this location have Cardio-Pulmonary Resuscitation certification.

Check this box if a provider at this location has Cardio-Pulmonary Resuscitation certification.

Check this box if staff at this location have Advanced Cardiac Life Support certification.

Check this box if a provider at this location has Advanced Cardiac Life Support certification.

Check this box if staff at this location have Pediatric Advanced Life Support certification.

Check this box if a provider at this location has Pediatric Advanced Life Support certification.

Check this box if staff at this location have Neonatal Advanced Life Support certification.

Check this box if a provider at this location has Neonatal Advanced Life Support certification.

Check this box if staff at this location have another certification not listed.

Check this box if a provider at this location has another certification not listed.

List all Certificates of Participation for laboratory services, such as CLIA, AAFP, COLA, CAP, or MLE.

Check this box if Laboratory Services are provided at this location.

Check this box if Laboratory Services are not provided at this location.

If the practice provides laboratory services, use this field area to list all certificates of participation (for example CLIA, AAFP, COLA, CAP, MLE) and check this box to indicate the certificate list is provided. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations' is 'Yes'

List all certifications related to X-ray services provided at this location.

Check this box if X-ray services are provided at this location.

Check this box if X-ray services are not provided at this location.

Check this box when the location provides X-ray services on-site, and then list all relevant X-ray certifications in the space provided. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations' is 'Yes'

Check this box if Radiology Services are provided.

Check this box if EKG services are provided.

Check this box if Pulmonary Function Tests are provided.

Check this box if Allergy Injections are provided.

Check this box if Allergy Skin Tests are provided.

Check this box if Routine Office Gynecology services are provided.

Check this box if Drawing Blood services are provided.

Check this box if Age Appropriate Immunizations are provided.

Check this box if Flexible Sigmoidoscopy services are provided.

Check this box if Tympanometry/Audiometry Tests are provided.

Check this box if Asthma Treatments are provided.

Check this box if Osteopathic Manipulations are provided.

Check this box if IV Hydration/Treatments are provided.

Check this box if Cardiac Stress Tests are provided.

Check this box if Physical Therapies are provided.

Check this box if other services not listed are provided.

List any additional office procedures provided, including surgical procedures.

If anesthesia is administered, specify the classes or categories of anesthesia used.

Check this box if anesthesia is administered at this practice location.

Check this box if anesthesia is not administered at this practice location.

State who administers anesthesia at this practice location.

Check this box if you have other practice locations and need to complete and submit Attachment F.

Enter the incident date. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the date the claim was filed. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Provide the current status of the claim or case. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the name of the professional liability carrier involved. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the address of the professional liability carrier. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the city of the professional liability carrier. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the state or country of the professional liability carrier. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the postal code of the professional liability carrier. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the phone number of the professional liability carrier. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the policy number. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the amount of the award or settlement. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the amount paid. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Check this box if the first reported malpractice claim was dismissed. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Check this box if the first reported malpractice claim was settled with prejudice. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Check this box if the first reported malpractice claim was settled without prejudice. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Check this box if the first reported malpractice claim resulted in a judgment for the defendant(s). Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Check this box if the first reported malpractice claim resulted in a judgment for the plaintiff(s). Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Check this box if the first reported malpractice claim was resolved through mediation or arbitration. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Provide a detailed description of the allegations. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Indicate if you were the primary defendant or a co-defendant. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the number of other co-defendants. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Describe your involvement in the case, such as attending or consulting. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Provide a detailed description of the alleged injury to the patient. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Check this box if, to your best knowledge, the first reported malpractice case was included in the National Practitioner Data Bank (NPDB). Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Check this box if, to your best knowledge, the first reported malpractice case was not included in the National Practitioner Data Bank (NPDB). Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the incident date. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the date the claim was filed. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Provide the current status of the claim or case. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the name of the professional liability carrier involved. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the address of the professional liability carrier. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the city of the professional liability carrier. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the state or country of the professional liability carrier. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the postal code of the professional liability carrier. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the phone number of the professional liability carrier. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the policy number. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the amount of the award or settlement. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the amount paid. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Check this box if the second reported malpractice claim was dismissed. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Check this box if the second reported malpractice claim was settled with prejudice. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Check this box if the second reported malpractice claim was settled without prejudice. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Check this box if the second reported malpractice claim resulted in a judgment for the defendant(s). Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Check this box if the second reported malpractice claim resulted in a judgment for the plaintiff(s). Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Check this box if the second reported malpractice claim was resolved through mediation or arbitration. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Provide a detailed description of the allegations. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Indicate if you were the primary defendant or a co-defendant. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the number of other co-defendants. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Describe your involvement in the case, such as attending or consulting. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Provide a detailed description of the alleged injury to the patient. Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Check this box if, to your best knowledge, the second reported malpractice case was included in the National Practitioner Data Bank (NPDB). Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Check this box if, to your best knowledge, the second reported malpractice case was not included in the National Practitioner Data Bank (NPDB). Fill only if 'Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?' is 'Yes'.

Enter the full name of the first partner in your practice for this row (first and last name as you want it recorded). Fill only if 'Row 1 - Check this box and attach list for large group' is 'No'. Fill only if 'Large Group Attachment' is 'No'.

Enter the full name of the second partner in your practice for this row (first and last name as you want it recorded). Fill only if 'Row 1 - Check this box and attach list for large group' is 'No'. Fill only if 'Large Group Attachment' is 'No'.

Enter the full name of the first partner listed in row 2 as it should appear on official records (first and last name, and middle name or initial if desired). Fill only if 'Row 1 - Check this box and attach list for large group' is 'No'. Fill only if 'Large Group Attachment' is 'No'.

Enter the full name of the second partner listed in row 2 as it should appear on official records (first and last name, and middle name or initial if desired). Fill only if 'Row 1 - Check this box and attach list for large group' is 'No'. Fill only if 'Large Group Attachment' is 'No'.

Enter the full name of the partner for the left entry in row 3 (provide the partner's full legal name as you want it listed). Fill only if 'Row 1 - Check this box and attach list for large group' is 'No'. Fill only if 'Large Group Attachment' is 'No'.

Enter the full name of the partner for the right entry in row 3 (provide the partner's full legal name as you want it listed). Fill only if 'Row 1 - Check this box and attach list for large group' is 'No'. Fill only if 'Large Group Attachment' is 'No'.

Enter the full name of the partner in your practice for the left-side entry on row 4. Fill only if 'Row 1 - Check this box and attach list for large group' is 'No'. Fill only if 'Large Group Attachment' is 'No'.

Enter the full name of the partner in your practice for the right-side entry on row 4. Fill only if 'Row 1 - Check this box and attach list for large group' is 'No'. Fill only if 'Large Group Attachment' is 'No'.

Check this box if the practice location accepts all new patients.

Check this box if the practice location accepts existing patients who have a change in their payor.

Check this box if the practice location accepts new patients only when they have a referral.

Check this box if the practice location accepts new patients who are covered by Medicare.

Check this box if the practice location accepts new patients who are covered by Medicaid.

Please provide an explanation if the patient acceptance criteria vary by health plan.

Check this box if the practice location accepts all new patients.

Check this box if the practice location accepts existing patients who have a change in their payor.

Check this box if the practice location accepts new patients who come with a referral.

Check this box if the practice location accepts new patients who are covered by Medicare.

Check this box if the practice location accepts new patients who are covered by Medicaid.

Provide the total number of hours patients are seen.

Enter the name of the department if the practice is hospital-based. Fill only if 'DO YOU HAVE HOSPITAL PRIVILEGES?' is 'Yes'

Enter the name of the entity or individual to whom the check should be made payable.

Check this box if a staff member at this location holds a Pediatric Advanced Life Support certification.

Check this box if the provider at this location holds a Pediatric Advanced Life Support certification.

Please provide your home telephone number.

Please provide your Social Security Number.

Check this box if your gender is female.

Check this box if your gender is male.

Enter the name of the post-graduate program or institution.

Check this box if the post-graduate education program was successfully completed.

Provide the attendance dates for the post-graduate program, in the format MM/YYYY to MM/YYYY.

Enter the name of the program director for the post-graduate education.

Provide the name of the current program director for the post-graduate education, if known.

Enter the primary practice phone number for this location, including country and area code as needed so staff can call this location.

Enter the practice fax number for this location, including country and area code if applicable so documents can be sent by fax.

Enter the practice contact email address for this location where administrative or patient communications should be sent.

Enter the practice location's main phone number, including area code and any extension if applicable. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Enter the practice location's fax number, including area code. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Enter the primary email address for this practice location. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Enter the back office or administrative phone number for this practice location, including area code. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Enter the site-specific Medicaid number assigned to this practice location. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Enter the practice location's federal Tax Identification Number (EIN). Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Provide a detailed specification for the 'Other' practice limitation.

Describe any other limitations applicable to the practice. Fill only if 'Other' is 'Yes'.

Check this box if the practice is limited to treating only male patients.

Check this box if the practice is limited to treating only female patients.

Enter the age limitation for this practice.

Check this box if there are other practice limitations not covered by the 'Male only' or 'Female only' options.

Check this box if the practice has a limitation that only male patients are seen. Fill only if 'have other practice locations' is 'Yes'.

Check this box if the practice has a limitation that only female patients are seen. Fill only if 'have other practice locations' is 'Yes'.

Please enter the age limit for this practice. Fill only if 'have other practice locations' is 'Yes'.

Check this box if the practice has other limitations not specified by gender. Fill only if 'have other practice locations' is 'Yes'.

Enter the number corresponding to this practice location.

Check this box if the practice location shown on this row is the primary practice location.

Enter the practice location's full street address, including building, suite or apartment number and P.O. box if applicable.

Enter the city where this practice location is physically located.

Enter the state, province, or country for this practice location (use the two-letter state code for U.S. addresses or the country name for international addresses).

Enter the postal code or ZIP code for this practice location (include ZIP+4 or international postal codes as applicable).

Check this box if this practice location is the clinician's primary practice location (the main location where they primarily provide services). Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Enter the full street address of the practice location, including street number, street name and suite or office number if applicable. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Enter the city in which the practice location is located. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Enter the state or province (or country for international addresses) for the practice location. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Enter the postal code or ZIP code for the practice location (include ZIP+4 or international postal format if applicable). Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Enter the identifier number for this practice location (the sequential location number used on Attachment F to distinguish multiple practice locations). Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Enter the official group or practice name exactly as you want it to appear in the provider directory. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Enter the legal group or corporate name exactly as it appears on the organization's IRS W-9 form. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment F if you have other practice locations.' is 'Yes'.

Check this box if the practice is currently operating at this location.

Check this box if the practice is not currently operating at this location.

Enter the date you expect to begin practicing at this location if you are not currently practicing there. Fill only if 'Currently practicing at this location — No' is 'Yes'. Fill only if 'No' is 'Yes'.

Enter the group name or practice name that should appear in the directory.

Provide the group or corporate name exactly as it appears on your IRS W-9 form.

Enter the name of the previous hospital where you had privileges.

Enter the dates during which you had privileges at this previous hospital.

Enter the street address of the previous hospital.

Enter the city where the previous hospital is located.

Enter the state or country where the previous hospital is located.

Enter the postal code for the previous hospital's address.

Check this box if you had full unrestricted privileges at the previous hospital.

Check this box if you did not have full unrestricted privileges at the previous hospital.

Enter the types of privileges you held at this previous hospital, such as provisional, limited, or conditional. Fill only if 'Previous Full Unrestricted Privileges - No' is 'No'.

Check this box if your privileges at the previous hospital were temporary.

Check this box if your privileges at the previous hospital were not temporary.

Enter the reason for the discontinuance of your privileges at this previous hospital.

Enter the name of the previous malpractice insurance carrier. Fill only if 'Time With Carrier' is less than 5 years.

Enter the full address of the previous malpractice insurance carrier. Fill only if 'Time With Carrier' is less than 5 years.

Enter the city of the previous malpractice insurance carrier's address. Fill only if 'Time With Carrier' is less than 5 years.

Enter the state or country of the previous malpractice insurance carrier's address. Fill only if 'Time With Carrier' is less than 5 years.

Enter the postal code of the previous malpractice insurance carrier's address. Fill only if 'Time With Carrier' is less than 5 years.

Enter the phone number of the previous malpractice insurance carrier. Fill only if 'Time With Carrier' is less than 5 years.

Enter the policy number for the previous malpractice insurance coverage. Fill only if 'Time With Carrier' is less than 5 years.

Enter the effective date of the previous malpractice insurance policy. Fill only if 'Time With Carrier' is less than 5 years.

Enter the expiration date of the previous malpractice insurance policy. Fill only if 'Time With Carrier' is less than 5 years.

Enter the amount of malpractice insurance coverage per occurrence for the previous policy. Fill only if 'Time With Carrier' is less than 5 years.

Enter the aggregate amount of malpractice insurance coverage for the previous policy. Fill only if 'Time With Carrier' is less than 5 years.

Check this box if your previous malpractice insurance coverage was individual. Fill only if 'Time With Carrier' is less than 5 years.

Check this box if your previous malpractice insurance coverage was shared. Fill only if 'Time With Carrier' is less than 5 years.

If applicable, specify any other type of malpractice insurance coverage not listed as individual or shared.

Enter the length of time the previous malpractice insurance carrier was used. Fill only if 'Time With Carrier' is less than 5 years.

Enter the full name of the primary hospital where you have admitting privileges. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Enter the start date of your affiliation with the primary hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Enter the street address of the primary hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Enter the city where the primary hospital is located. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Enter the state or country where the primary hospital is located. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Enter the postal code for the primary hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Enter the phone number of the primary hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Enter the fax number of the primary hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Enter the email address for the primary hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Check this box if you have full unrestricted privileges at the primary hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Check this box if you do not have full unrestricted privileges at the primary hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Describe the types of privileges you hold at the primary hospital, such as provisional, limited, or conditional. Fill only if 'Full Unrestricted Privileges - No' is 'No'.

Check this box if your privileges at the primary hospital are temporary. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Check this box if your privileges at the primary hospital are not temporary. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Enter the percentage of your total admissions to all hospitals in the past year that were to this primary hospital. Fill only if 'Hospital Privileges Yes' is 'Yes'.

Provide the primary medical specialty for which you are certified.

Enter the name of the board that issued your certification. Fill only if 'Board Certified Yes' is 'Yes'.

Check this box if you are board certified in your primary specialty.

Check this box if you are not board certified in your primary specialty.

Provide the initial date your primary specialty certification was issued. Fill only if 'Board Certified Yes' is 'Yes'.

Enter the date(s) of your recertification, if applicable. Fill only if 'Board Certified Yes' is 'Yes'.

Provide the expiration date of your primary specialty certification, if applicable. Fill only if 'Board Certified Yes' is 'Yes'.

Enter the name of the institution that issued this professional degree.

Enter the street address of the issuing institution.

Enter the city of the issuing institution.

Enter the state or country of the issuing institution.

Enter the postal code of the issuing institution.

Enter the specific professional degree obtained.

Enter the attendance dates for this professional degree, including both the start and end dates.

Enter the provider's UPIN (Unique Physician Identification Number) as assigned by the relevant authority.

Enter the provider's National Provider Identifier assigned for billing and identification purposes.

Please specify any other type of public transportation that makes this location accessible. Fill only if 'Other Public Transportation' is 'Yes'.

Check this box if the practice location is accessible by bus.

Check this box if the practice location is accessible by regional train.

Check this box if the practice location is accessible by other forms of public transportation not listed.

Enter the applicant's initials and the current date in MM/DD/YYYY format. Fill only if 'Hospital(s) to which you are applying' is provided

Enter your signature by signing your full legal name as it should appear for this authorization or type your full legal name if completing electronically. Fill only if 'Hospital(s) to which you are applying' is provided

Enter your full legal name as you want it printed (first, middle, last) using print or typed characters. Fill only if 'Hospital(s) to which you are applying' is provided

Enter the last four digits of your Social Security Number (SSN) or your National Provider Identifier (NPI). Fill only if 'Hospital(s) to which you are applying' is provided

Check this box if you are attaching a copy of your DEA or state DPS Controlled Substances Registration Certificate.

Check this box if you are attaching a copy of other Controlled Dangerous Substances Registration Certificate(s).

Check this box if you are attaching a copy of your current professional liability insurance policy face sheet, showing expiration dates, limits, and applicant's name.

Check this box if you are attaching copies of IRS W-9s for verification of each tax identification number used.

Check this box if you are attaching a copy of your workers compensation certificate of coverage, if applicable. Fill only if 'DO NURSE PRACTITIONERS, PHYSICIAN ASSISTANTS, MIDWIVES, SOCIAL WORKERS OR OTHER NON-PHYSICIAN PROVIDERS CARE FOR PATIENTS AT THIS PRACTICE LOCATION?' is 'Yes'.

Check this box if you are attaching a copy of your CLIA certifications, if applicable. Fill only if 'DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE? (Laboratory Services)' is 'Yes'.

Check this box if you are attaching copies of your radiology certifications, if applicable. Fill only if 'DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE? (X-ray)' is 'Yes'.

Check this box if you are attaching a copy of your DD214, record of military service, if applicable.

Check this box if there are no office hours on Saturday.

Please enter the start time for Saturday morning office hours.

Please enter the end time for Saturday morning office hours. Fill only if 'Saturday No Office Hours' is 'No'.

Please enter the start time for Saturday afternoon office hours. Fill only if 'Saturday No Office Hours' is 'No'.

Please enter the end time for Saturday evening office hours. Fill only if 'Saturday No Office Hours' is 'No'.

Check this box if there are no office hours for patients on Saturday.

Provide any general notes or specific conditions regarding Saturday patient hours. Fill only if 'Saturday No Office Hours' is 'No'.

Enter the patient hours for Saturday morning. Fill only if 'Saturday No Office Hours' is 'No'.

Enter the patient hours for Saturday afternoon. Fill only if 'Saturday No Office Hours' is 'No'.

Enter the patient hours for Saturday evening. Fill only if 'Saturday No Office Hours' is 'No'.

Enter the name of the second colleague providing regular coverage.

Enter the specialty of the second colleague providing regular coverage.

Enter the number of the second disclosure question for which you are providing an explanation. Fill only if 'a Disclosure Question' is 'Yes'.

Provide a detailed explanation for the 'yes' answer to the second disclosure question. Fill only if 'Second Disclosure Question Number' is a question number other than 16.

Provide the dates for the second gap in your work history. Fill only if 'Work History' has gaps greater than six months

Provide a detailed explanation for the second gap in your work history. Fill only if 'Work History' has gaps greater than six months

Enter the full legal name of the other hospital where you hold privileges. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the date your privileges at this hospital began. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the hospital's street address, including suite or floor information if applicable. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the city where the hospital is located. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the state or country in which the hospital is located. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the postal or ZIP code for the hospital's address. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the hospital's main phone number, including area code. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the hospital's fax number, if available. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter a contact email address for the hospital or department where you have privileges. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Check this box if, for the second hospital listed, you currently have full, unrestricted privileges. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Check this box if, for the second hospital listed, you do not have full, unrestricted privileges (i.e., your privileges are restricted, provisional, or conditional). Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Describe the types of privileges you hold at this hospital (for example provisional, limited, conditional, etc.). Fill only if 'Second Hospital - Full Unrestricted Privileges? No' is 'Yes'. Fill only if 'Second Hospital - Full Unrestricted Privileges? No' is 'Yes'.

Check this box if the privileges you hold at the second hospital are temporary or time-limited. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Check this box if the privileges you hold at the second hospital are not temporary (i.e., they are ongoing/permanent). Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the percentage of your total admissions in the past year that were to this specific hospital. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'. Fill only if 'Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.' is 'Yes'.

Enter the type of the second license.

Enter the identification number for the second license.

Enter the state where the second license is registered.

Enter the original date when the second license was issued.

Enter the date when the second license expires.

Check this box if you currently practice in the state where your second license is registered.

Check this box if you do not currently practice in the state where your second license is registered.

Enter the name of the institution that issued the second professional degree. Fill only if 'Received other professional degrees' is 'Yes'.

Enter the full mailing address of the institution that issued the second professional degree. Fill only if 'Second Other Professional Degree Issuing Institution' is filled.

Enter the city where the institution that issued the second professional degree is located. Fill only if 'Second Other Professional Degree Issuing Institution' is filled.

Enter the state or country where the institution that issued the second professional degree is located. Fill only if 'Second Other Professional Degree Issuing Institution' is filled.

Enter the postal code of the institution that issued the second professional degree. Fill only if 'Second Other Professional Degree Issuing Institution' is filled.

Enter the name of the second professional degree obtained. Fill only if 'Second Other Professional Degree Issuing Institution' is filled.

Enter the attendance dates for the second professional degree. Fill only if 'Second Other Professional Degree Issuing Institution' is filled.

Enter the specialty or program focus for the second post-graduate training (for example, Internal Medicine, Pediatrics, or Fellowship specialty). Fill only if 'Post-Graduate Program 2 - Internship', 'Post-Graduate Program 2 - Residency', 'Post-Graduate Program 2 - Fellowship', 'Post-Graduate Program 2 - Teaching Appointment' is 'Yes' in any fields selection. Fill only if 'Post-Graduate Program 2 - Internship', 'Post-Graduate Program 2 - Residency', 'Post-Graduate Program 2 - Fellowship', 'Post-Graduate Program 2 - Teaching Appointment' is 'Yes', any.

Check this box if the second post-graduate program you are reporting was an Internship.

Check this box if the second post-graduate program you are reporting was a Residency.

Check this box if the second post-graduate program you are reporting was a Fellowship.

Check this box if the second post-graduate program you are reporting was a Teaching Appointment.

Enter the full name of the institution, hospital, or training program where you completed the second post-graduate program. Fill only if 'Post-Graduate Program 2 - Internship', 'Post-Graduate Program 2 - Residency', 'Post-Graduate Program 2 - Fellowship', 'Post-Graduate Program 2 - Teaching Appointment' is 'Yes' in any fields selection. Fill only if 'Post-Graduate Program 2 - Internship', 'Post-Graduate Program 2 - Residency', 'Post-Graduate Program 2 - Fellowship', 'Post-Graduate Program 2 - Teaching Appointment' is 'Yes', any.

Enter the street address of the institution for the second post-graduate program, including building number, street name, and suite or unit if applicable. Fill only if 'Post-Graduate Program 2 - Internship', 'Post-Graduate Program 2 - Residency', 'Post-Graduate Program 2 - Fellowship', 'Post-Graduate Program 2 - Teaching Appointment' is 'Yes' in any fields selection. Fill only if 'Post-Graduate Program 2 - Internship', 'Post-Graduate Program 2 - Residency', 'Post-Graduate Program 2 - Fellowship', 'Post-Graduate Program 2 - Teaching Appointment' is 'Yes', any.

Enter the city where the institution for the second post-graduate program is located. Fill only if 'Post-Graduate Program 2 - Internship', 'Post-Graduate Program 2 - Residency', 'Post-Graduate Program 2 - Fellowship', 'Post-Graduate Program 2 - Teaching Appointment' is 'Yes' in any fields selection. Fill only if 'Post-Graduate Program 2 - Internship', 'Post-Graduate Program 2 - Residency', 'Post-Graduate Program 2 - Fellowship', 'Post-Graduate Program 2 - Teaching Appointment' is 'Yes', any.

Enter the state, province or country of the institution for the second post-graduate program (spell out the country for non‑US addresses). Fill only if 'Post-Graduate Program 2 - Internship', 'Post-Graduate Program 2 - Residency', 'Post-Graduate Program 2 - Fellowship', 'Post-Graduate Program 2 - Teaching Appointment' is 'Yes' in any fields selection. Fill only if 'Post-Graduate Program 2 - Internship', 'Post-Graduate Program 2 - Residency', 'Post-Graduate Program 2 - Fellowship', 'Post-Graduate Program 2 - Teaching Appointment' is 'Yes', any.

Enter the postal or ZIP code for the institution's address for the second post-graduate program. Fill only if 'Post-Graduate Program 2 - Internship', 'Post-Graduate Program 2 - Residency', 'Post-Graduate Program 2 - Fellowship', 'Post-Graduate Program 2 - Teaching Appointment' is 'Yes' in any fields selection. Fill only if 'Post-Graduate Program 2 - Internship', 'Post-Graduate Program 2 - Residency', 'Post-Graduate Program 2 - Fellowship', 'Post-Graduate Program 2 - Teaching Appointment' is 'Yes', any.