Maine Uniform Application for Initial Appointment Instructions

Enter any additional fellowship details, explanations, or notes related to your post-graduate training (use a separate sheet if more space is needed).

Enter any additional information or explanations relevant to your application (for example gaps in training, work history, insurance coverage, hospital affiliations, or other details), using a separate sheet if more space is needed.

Enter the main alternate or additional mailing street address (street number and name) where you can receive correspondence for this application.

Enter any secondary address details for the alternate address such as apartment, suite, unit number, building, or other delivery information.

Check this box when the adjacent first alternate address line is being provided and should be used as an additional/alternate contact/mailing address.

Check this box when the adjacent second alternate address line is being provided and should be used as an additional/alternate contact/mailing address.

Check this box when the adjacent alternate address (the upper address line in the block) is applicable and should be considered an additional or alternate address for the applicant.

Check this box when the adjacent alternate address (the upper address line in the block) is applicable and should be considered an additional or alternate address for the applicant.

Provide a clear, detailed description of the alleged wrongdoing or negligence, including what occurred, who was involved, relevant dates and locations, and any supporting facts or circumstances.

Enter the date on which the alleged malpractice incident occurred.

Enter the date on which the lawsuit related to this alleged incident was filed.

Enter your full name as you want it to appear on the application (include first, middle and last names and any suffixes if applicable).

Enter your current legal last (family) name exactly as it appears on official documents.

Enter your current legal first (given) name as it appears on official documents.

Enter your middle name or initial if you use one; leave blank if none.

Enter any suffix that follows your name such as Jr., Sr., II, III, etc., or leave blank if none.

Enter your professional title(s) or degree(s) such as MD, DO, RN, PA, PhD, including any credentials you use after your name.

Enter any other surname or the name you used when your degree was conferred (for example a maiden name or previous legal name).

Check this box if the applicant's gender is male.

Check this box if the applicant's gender is female.

Enter the full name or names of the co-defendant(s) associated with this claim, listing multiple names separated by commas. Fill only if 'Co-Defendant with' is 'Yes'.

Check this box if, in the listed malpractice claim/suit, you served as a co-defendant (not the sole defendant) and will provide the name(s) of the other defendant(s) on the line provided.

Enter the applicant's role in this claim if it does not match 'Sole Defendant' or 'Co-Defendant' (for example, 'Witness', 'Consulting Physician', 'Named but not Practicing', etc.). Fill only if 'Other' is 'Yes'.

Check this box when your role/status in the malpractice claim was not 'Sole Defendant' or 'Co-Defendant' and you will provide the alternate role on the line provided.

Enter the information confirming your status as the sole defendant in this claim — for example your name and any brief detail or note clarifying your role as sole defendant. Fill only if 'Sole Defendant' is 'Yes'.

Check this box if you were the only defendant named in the malpractice claim or suit (i.e., your status was Sole Defendant).

Enter the date on which the applicant signed the form.

Enter your Social Security Number as it appears on official documents, or leave blank if you do not have one.

Enter your date of birth.

Enter the city and state for U.S. births or the city and country for births outside the United States.

Enter your country of citizenship or your citizenship status (e.g., United States, Canada, dual citizenship).

Enter your ECFMG identification number issued by the Educational Commission for Foreign Medical Graduates, or leave blank if not applicable.

Enter the date associated with the ECFMG number above, if applicable.

Enter the full name of the insurance carrier or organization that covered you at the time the alleged incident occurred.

Provide the full name of the court where the lawsuit was filed followed by the official case or docket number for that matter.

Enter the date on which this case was closed without any payment or settlement. Fill only if 'Closed without payment' is 'Yes'.

Check this box if the malpractice claim was ultimately closed with no payment made (no settlement or judgment paid); provide the closure date on the adjacent date line.

Enter the date as of which the notice of claim was filed for this case. Fill only if 'Notice of Claim Filed' is 'Yes'.

Check this box if a Notice of Claim has been filed in this matter; enter the effective date in the adjacent 'Date as of' field.

Enter the date indicating the status of the case as being pending before a malpractice panel (the "date as of" when the case remained pending). Fill only if 'Pending before malpractice panel' is 'Yes'.

Check this box if the claim or suit is currently pending before a malpractice panel (enter the applicable 'date as of' next to the label).

Enter the date on which the case was pending in court (the effective 'as of' date for the pending-in-court status). Fill only if 'Pending in court' is 'Yes'.

Check this box if the claim or suit is currently pending in court (then provide the 'Date as of' for the current status).

Enter the dollar amount of the pre-trial settlement awarded or agreed to for this case. Fill only if 'Pre-Trial Settlement' is 'Yes'.

Enter the date as of which the pre-trial settlement amount applies. Fill only if 'Pre-Trial Settlement' is 'Yes'.

Check this box if the case was resolved by a pre-trial settlement, and then provide the settlement amount and the date as requested.

Enter the date on which the verdict was recorded or became effective in favor of the defendant. Fill only if 'Verdict for Defendant' is 'Yes'.

Check this box if the final verdict in the referenced case was for the defendant (i.e., the decision favored the defendant); provide the date of that verdict on the line.

Enter the monetary amount awarded to the plaintiff for this verdict. Fill only if 'Verdict for Plaintiff' is 'Yes'.

Enter the date to which the plaintiff verdict amount applies. Fill only if 'Verdict for Plaintiff' is 'Yes'.

Check this box if the case resulted in a verdict in favor of the plaintiff (enter the award amount and the date of the verdict on the lines provided).

Check this box if you do have clinical privileges at any hospital for the specialty you listed above.

Check this box if you do not have clinical privileges at any hospital for the specialty you listed above.

Enter the U.S. state or other issuing jurisdiction for the eighth license (full name or postal abbreviation).

Enter the professional license type or category for the eighth license (for example MD, DO, RN, PA, etc.).

Enter the registration or license number assigned to the eighth license as issued by the licensing authority.

Enter the date when the eighth license was originally issued.

Enter the expiration or renewal date for the eighth license.

Enter the current status of the eighth license (for example active, expired, suspended, revoked).

Enter the U.S. state or jurisdiction that issued the fifth license (e.g., 'CA' or 'California').

Enter the type or category of the fifth license (for example, 'RN', 'Driver', 'Real Estate').

Enter the full license or registration number for the fifth license exactly as shown on the license.

Enter the date the fifth license was issued.

Enter the expiration date of the fifth license.

Enter the current status of the fifth license (for example, 'Active', 'Expired', or 'Suspended').

Enter the U.S. state or jurisdiction that issued this license (use the official two-letter abbreviation or full state name as applicable).

Enter the license type or classification (for example, Professional, Driver, Nursing, Contractor, etc.).

Enter the exact license number as shown on the license, including any letters, dashes, or other characters.

Enter the date on which this license was originally issued.

Enter the date on which this license expires or expired.

Enter the current status of the license (for example: Active, Inactive, Suspended, Revoked, Expired).

Enter the U.S. state or issuing jurisdiction for the fourth license (e.g., CA or California).

Enter the type or classification of the fourth license (for example 'RN', 'CPA', 'Driver', or other license type).

Enter the exact license number for the fourth license as shown on the license, including any letters, numbers and punctuation.

Provide the date the fourth license was issued by the licensing authority.

Provide the expiration date for the fourth license as shown on the license.

Enter the current status of the fourth license (for example: Active, Expired, Suspended, or Pending).

Enter the U.S. state or other jurisdiction that issued the ninth license.

Enter the license type or category for the ninth license (for example, MD, DO, RN, etc.).

Enter the license number for the ninth license exactly as it appears on the license, including any letters or punctuation.

Enter the date the ninth license was issued.

Enter the expiration date for the ninth license.

Enter the current status of the ninth license (for example, Active, Inactive, Suspended, or Revoked).

Enter the U.S. state or territory that issued the license (either the two-letter postal abbreviation or the full state/territory name).

Enter the license or credential type as shown on the license (for example: RN, LPN, CPA).

Enter the complete license number exactly as printed on the license, including any letters, hyphens, or other characters.

Enter the date the license was issued.

Enter the license's expiration date.

Enter the current status of the license (for example: Active, Inactive, Suspended, or Revoked).

Enter the U.S. state or other issuing jurisdiction for the seventh license.

Enter the license classification or type for the seventh license (for example: MD, DO, RN, etc.).

Enter the full license number or identifier exactly as issued for the seventh license.

Enter the date the seventh license was issued.

Enter the expiration date for the seventh license.

Enter the current status of the seventh license (for example: Active, Expired, Suspended, Revoked).

Enter the U.S. state or issuing jurisdiction for the sixth license (e.g., a two-letter state abbreviation or full state name).

Enter the license type or classification for the sixth license (for example, Driver, Professional, Medical, etc.).

Enter the full license number for the sixth license exactly as it appears on the license.

Enter the date the sixth license was issued.

Enter the expiration date of the sixth license.

Enter the current status of the sixth license (for example, Active, Expired, Suspended).

Enter the U.S. state or other jurisdiction that issued the third license.

Enter the classification or type of the third license (for example, the profession or license category).

Enter the official license number or identifier for the third license, including any letters or punctuation as shown on the license.

Enter the date the third license was issued.

Enter the expiration date of the third license.

Enter the current status of the third license (for example, Active, Expired, Suspended).

Check this box if you have ever been denied registration by the U.S. Drug Enforcement Administration (DEA) or your DEA registration has ever been modified, restricted, suspended, or revoked.

Check this box if you have never been denied DEA registration and your DEA registration has never been modified, restricted, suspended, or revoked.

Check this box if you have ever been denied registration by any state to prescribe or dispense controlled substances or if your state registration has ever been modified, restricted, suspended, or revoked.

Check this box if you have never been denied registration by any state to prescribe or dispense controlled substances and your state registration has never been modified, restricted, suspended, or revoked.

Check this box if there are currently any proceedings pending that could result in modification, restriction, suspension or revocation of your DEA registration.

Check this box if there are no proceedings currently pending that could result in modification, restriction, suspension or revocation of your DEA registration.

Check this box if you have ever voluntarily withdrawn your narcotics application, resigned your DEA registration, or permitted it to lapse.

Check this box if you have never voluntarily withdrawn your narcotics application, resigned your DEA registration, nor permitted it to lapse.

Enter the full federal DEA registration number for the first registration (exact alphanumeric identifier as shown on your DEA certificate).

Enter the date the first DEA registration was issued.

Enter the expiration date for the first DEA registration.

Enter the federal DEA registration number for the second registration row (the alphanumeric identifier assigned by the DEA).

Enter the date the federal DEA registration was issued for this second registration entry.

Enter the expiration date for the federal DEA registration shown in this second registration row.

Enter the federal DEA registration number for the third registration entry (letters and/or numbers as shown on the DEA certificate).

Enter the date the third DEA registration was issued.

Enter the expiration date for the third DEA registration.

Enter the full name of the fellowship institution.

Enter the full mailing address of the fellowship institution, including city, state and ZIP.

Enter the starting date when you began the fellowship.

Enter the ending date when you completed or left the fellowship.

Enter the fellowship specialty or subspecialty (for example, cardiology or oncology).

Enter the program director's full name for this fellowship.

Enter the program director's academic or professional degree (for example, MD, DO, PhD).

Enter the program director's job title or position.

Enter the program director's phone number, including area code.

Enter the program director's fax number, including area code, if available.

Enter the program director's email address.

Enter the full name of the hospital or medical institution for this (fifth) affiliation.

Enter the street address for the fifth institution (building number, street name, suite or floor if applicable).

Enter the city, state and ZIP code for the fifth institution in a single line.

Enter the primary phone number for the fifth institution (include area code).

Enter the fax number for the fifth institution (include area code), if available.

Enter your position, title or staff category held at the fifth institution.

Enter the department or service line where you worked at the fifth institution.

Enter the name of the department chief or supervisor associated with your role at the fifth institution.

Enter the start date when you began affiliation at the fifth institution.

Enter the end date when your affiliation at the fifth institution ended (or enter 'Present' if ongoing).

Enter the full name of the hospital for this affiliation (your current primary hospital if applicable).

Enter the hospital's street address, including suite or unit if applicable.

Enter the city, state and ZIP code for the hospital.

Enter the hospital's main telephone number, including area code and extension if needed.

Enter the hospital's fax number, including area code.

Enter your job title and staff category or privileges held at this hospital (for example, Attending, Resident).

Enter the department or clinical service where you worked (for example, Emergency Medicine, Surgery).

Enter the name and title of the department chief or clinical director for this service.

Enter the starting date when your affiliation at this hospital began.

Enter the end date of your affiliation at this hospital, or indicate that it is ongoing (e.g., 'Present').

Enter the full name of the first prior insurance company or carrier.

Enter the street address (and suite or unit, if applicable) for the first prior insurance carrier.

Enter the city, state and ZIP code for the first prior insurance carrier's address.

Enter the institution, practice, or employer affiliation associated with this prior insurance coverage, if any.

Enter the primary phone number for the first prior insurance carrier, including area code and extension if applicable.

Enter the fax number for the first prior insurance carrier, including area code if applicable.

Enter the policy number assigned to the first prior insurance coverage.

Enter the coverage start date for this first prior policy.

Enter the coverage end date for this first prior policy.

Enter the incident coverage amount for this first prior policy.

Enter the aggregate coverage amount for this first prior policy.

Enter the full name of the college, university, or professional/graduate school where you obtained this qualification.

Enter the degree, diploma, certificate, or credential awarded for this program (for example: MD, PhD, MSc).

Enter the complete mailing address of the institution (street address and any suite or building information).

Enter the date when you began attending this program or institution.

Enter the date when you stopped attending this program or institution.

Enter the date on which your degree or award was conferred for this program.

Enter the city, state/province and ZIP or postal code where the institution is located.

Enter the country in which the institution is located.

Enter the reference's first (given) name for the Current Department Chief or Residency/Fellowship Director.

Enter the reference's last (family) name for the Current Department Chief or Residency/Fellowship Director.

Enter the reference's professional degree or credentials (for example MD, DO, DMD, PA).

Enter the medical or professional specialty or discipline in which the reference practices.

Enter the reference's primary email address for professional contact.

Enter the reference's primary telephone number for contact, including area or country code as needed.

Enter the reference's fax number for professional correspondence, if available.

Enter the reference's full street address, including suite or apartment number if applicable.

Enter the city, state (or province) and ZIP/postal code for the reference's address.

Describe the capacity or role in which this individual observed your clinical abilities (for example supervising attending, program director, clinical supervisor).

Enter the full name of the institution where you completed your first residency.

Enter the full street address of the residency institution, including city, state and ZIP code.

Enter the start date of the residency.

Enter the end date of the residency.

Enter the specialty or program focus for this residency (for example, Internal Medicine, Pediatrics).

Enter the full name of the program director for this residency.

Enter the academic degree(s) held by the program director (for example, MD, DO, PhD).

Enter the program director's professional title or position.

Enter the main phone number to contact the residency program or program director.

Enter the fax number for the residency program or program director.

Enter the email address for the residency program or program director for contact.

Enter the full name of the organization or employer for this first work history/professional affiliation entry.

Enter the street or mailing address of the organization for this entry.

Enter the city, state (or province) and ZIP/postal code for the organization's address.

Enter the full name of the primary contact person at the organization for this affiliation.

Enter the primary telephone number for the contact or organization, including area or country code as needed.

Enter the organization's or contact's fax number, if available.

Enter the contact person's or organization's email address for correspondence regarding this affiliation.

Enter the job title or professional position you held at this organization.

Enter the start date when you began the position or affiliation at this organization.

Enter the end date when your employment or affiliation at this organization ended.

Enter the name of the fourth hospital or medical institution where you held staff membership or clinical privileges.

Enter the street address for this institution (building, suite or P.O. box as applicable).

Enter the city, state and ZIP code for this institution.

Enter the main phone number for this institution, including area code.

Enter the fax number for this institution, including area code if applicable.

Enter the position title or staff category you held at this institution.

Enter the department or service to which you were assigned at this institution.

Enter the name of the department chief or supervisor responsible for your department at this institution.

Enter the start date when you began your affiliation at this institution.

Enter the end date when your affiliation at this institution ended, or indicate if it is ongoing.

Enter the given (first) name of your fourth professional reference as it appears on professional records.

Enter the family (last) name of your fourth professional reference.

Enter the professional degree(s) or credentials for your fourth reference (for example, MD, DO, PA, NP).

Enter the medical or professional specialty of your fourth reference (for example, Family Medicine, Internal Medicine).

Enter the primary email address for your fourth professional reference for contact purposes.

Enter the primary telephone number for your fourth reference, including area code as needed.

Enter the fax number for your fourth professional reference (this field is required if a fax is available).

Enter the street or mailing address for your fourth professional reference.

Enter the city, state and ZIP (or postal) code for your fourth reference's address.

Briefly describe in what capacity this individual has observed your clinical abilities (for example, supervising physician, colleague, program director).

Enter the full name of the organization for this fourth work history/professional affiliation entry.

Enter the street address of the organization (street, suite or building) for this fourth entry.

Enter the city, state and ZIP or postal code for the organization's address for this fourth entry.

Enter the full name of the primary contact person at the organization for this fourth entry.

Enter the main contact phone number (include area code) for the organization or contact person for this fourth entry.

Enter the fax number for the organization or contact person for this fourth entry, if applicable.

Enter the email address for the organization or contact person for this fourth entry.

Enter the position title or role you held at the organization for this fourth entry.

Enter the start date when you began the position or affiliation at this organization for this fourth entry.

Enter the end date when your position or affiliation at this organization ended for this fourth entry.

Enter your full home street address, including apartment or suite number if applicable.

Enter the city, state and ZIP code for your home address.

Enter your primary phone number including area code; indicate whether this is a home or cell number if requested.

Enter your current email address that the facility should use for contact.

Enter your CAQH identification number as assigned to you by CAQH.

Enter your National Provider Identifier (NPI) number.

Check this box when the phone number entered on the Phone line is your home (landline) number.

Check this box when the phone number entered on the Phone line is your mobile/cell number.

Enter the internship program director's full name (first and last name).

Enter the director's academic or professional degree/credential (for example, MD, PhD, MS).

Enter the director's job title or position within the program (for example, Program Director, Chief Resident).

Enter the director's primary phone number, including area code and country code if applicable.

Enter the director's fax number including area code if available, or leave blank if not applicable.

Enter the director's primary email address for contact.

Enter the name of the institution where the internship was completed.

Enter the full address of the internship institution (street address and any suite or unit information).

Enter the starting date of the internship.

Enter the ending date of the internship.

Enter the internship's specialty, discipline, or primary area of clinical/academic focus.

Enter the full name of the practice, group, or hospital you will be joining.

Enter the date you expect to begin work at the practice or hospital.

Check this box if you have ever had your license to practice medicine in any state or jurisdiction restricted, suspended, revoked, denied, placed on probation, or otherwise disciplined (voluntarily or involuntarily).

Check this box if you have never had your license to practice medicine in any state or jurisdiction restricted, suspended, revoked, denied, placed on probation, or otherwise disciplined.

Check this box if there are no proceedings currently pending that could result in restriction, suspension, revocation, denial, probationary conditions, or other disciplinary action against your license.

Check this box if there are any proceedings currently pending that could result in restriction, suspension, revocation, denial, probationary conditions, or other disciplinary action against your license.

Check this box if you have ever voluntarily withdrawn an application for licensure, resigned your license, or permitted it to lapse.

Check this box if you have never voluntarily withdrawn an application for licensure, resigned your license, nor permitted it to lapse.

Check this box if you are currently participating in the Maintenance of Certification (MOC) program. Fill only if 'Required to participate in MOC — Yes' is 'Yes'.

Check this box if you are not currently participating in the Maintenance of Certification (MOC) program. Fill only if 'Required to participate in MOC — Yes' is 'Yes'.

Check this box if you are required (by your board or employer) to participate in the Maintenance of Certification (MOC) program.

Check this box if you are not required to participate in the Maintenance of Certification (MOC) program.

Check this box if you have never been named in any malpractice claim or lawsuit (i.e., you have no claims to report).

Enter the official name of the first additional office or group.

Enter the street address or PO Box for the first office, including number and street name.

Enter the city, state (abbreviation) and ZIP code for the first office.

Enter the primary phone number for the first office, including area code.

Enter the fax number for the first office, including area code.

Enter the general email address for the first office.

Enter the full name of the office manager for the first office (include title if desired).

Provide a contact phone number or email address for the first office manager.

Enter the full name of the credentialing contact for the first office.

Provide a contact phone number or email address for the first office’s credentialing contact.

Enter the official name of the office, practice, or group for this second alternate location.

Enter the street address or P.O. Box for this second office location's mailing address.

Enter the city, state and ZIP code for the second office location.

Enter the main telephone number for the second office location.

Enter the fax number for the second office location, if available.

Enter the primary email address for the second office location.

Enter the full name of the office manager responsible for this second location.

Enter the office manager's contact information for the second location (phone number and/or email address).

Enter the full name of the person responsible for credentialing at this second office location.

Enter the credentialing contact's phone number and/or email address for the second office location.

Enter the official name of the office or group for the third alternate location.

Enter the street address or PO Box for the third office location.

Enter the city, state and ZIP/postal code for the third office location.

Enter the primary phone number for this office location (include area code).

Enter the fax number for this office location, if applicable (include area code).

Enter the office email address to be used for general contact.

Enter the full name of the office manager for the third office location.

Enter the office manager's phone number and/or email address (you may separate multiple entries with a slash or comma).

Enter the full name of the person responsible for credentialing at the third office location.

Enter the credentialing contact's phone number and/or email address (you may separate multiple entries with a slash or comma).

Enter the name of your first "Other Specialty" (the medical/specialty area being reported).

Enter the certification or certificate number issued by the specialty board for this specialty.

Enter the date on which this board certification was awarded.

Enter the expiration date of this board certification, if applicable. Fill only if 'Other Specialty (First) - Lifetime No' is 'Yes'.

Enter the full name of the specialty board that granted this certification.

Check this box if the board certification for your first 'Other Specialty' is a lifetime certification (does not expire).

Check this box if the board certification for your first 'Other Specialty' is not a lifetime certification (it has an expiration date).

Enter the name of the other specialty or subspecialty for this second certification.

Enter the certification number assigned by the issuing board for this specialty.

Enter the date the board awarded this certification.

Enter the expiration date of this certification. Fill only if 'Second Other Specialty - Lifetime No' is 'Yes'.

Enter the name of the specialty board that issued this certification.

Check this box if the board certification for your second 'Other Specialty' is a lifetime certification (i.e., it does not expire).

Check this box if the board certification for your second 'Other Specialty' is not a lifetime certification (i.e., it has an expiration date).

Enter the full name of the primary insurance company that provides the policy.

Enter the primary carrier's street address (P.O. box or delivery address) for correspondence.

Enter the city, state and ZIP/postal code for the primary carrier's address.

Enter the name of any institution or employer affiliated with this primary insurance carrier, if applicable.

Enter the primary carrier's telephone number (include area code) for contact purposes.

Enter the primary carrier's fax number, if available.

Enter the policy number assigned to your coverage by the primary insurance carrier.

Enter the start date of the coverage period provided by the primary carrier.

Enter the end date of the coverage period provided by the primary carrier.

Enter the coverage limit amount for a single incident under the primary policy.

Enter the total aggregate coverage limit amount under the primary policy.

Enter the full legal name of the primary office or group practice you will be joining.

Enter the office street address or P.O. Box, including suite or unit number if applicable.

Enter the office city, two‑letter state abbreviation, and ZIP or postal code for the primary location.

Enter the main office telephone number, including area code and extension if applicable.

Enter the office fax number, including area code.

Enter the primary office email address to be used for correspondence.

Enter the full name of the office manager or primary administrative contact for this location.

Provide the office manager's preferred contact information (phone number and/or email) for direct contact.

Enter the full name of the person responsible for credentialing at this office.

Provide the credentialing contact's phone number and/or email address for credentialing communications.

Enter the certification or license number assigned by the board for your primary specialty, including any letters, dashes, or leading zeros.

Enter the date your primary board certification was issued.

Enter the expiration date of your primary board certification. Fill only if 'Lifetime No' is 'Yes'.

Enter the full name of the specialty board that issued your primary certification (for example, American Board of Internal Medicine).

Check this box if your primary specialty board certification is a lifetime certification (no expiration).

Check this box if your primary specialty board certification is not a lifetime certification (it has an expiration date).

Enter the name of your primary specialty—the area in which you spend 50% or more of your professional time.

Enter the full name of the professional or graduate school or university you attended for this entry.

Enter the degree awarded or expected for this program (for example, M.D., Ph.D., M.S., MBA).

Enter the street address, P.O. box, or department address for the college or university.

Enter the date you began attendance in this professional/graduate program.

Enter the date you ended attendance in this professional/graduate program (or anticipated end date).

Enter the date the degree was conferred or is expected to be conferred for this program.

Enter the city, state/province and postal code for the college or university's location.

Enter the country where the college or university is located.

Enter the full name of the specialty board you are pursuing certification from (leave blank if not pursuing). Fill only if 'Pursuing Certification (If Not Board Certified) - Yes' is 'Yes'.

Provide the expected date when you anticipate completing the certification process. Fill only if 'Pursuing Certification (If Not Board Certified) - Yes' is 'Yes'.

Explain why you are not pursuing board certification and describe any unsuccessful attempts or relevant details (use multiple lines as needed). Fill only if 'Pursuing Certification (If Not Board Certified) - No' is 'Yes'.

Check this box if, after answering 'No' to pursuing certification, you DO have postgraduate training sufficient to meet the requirements of a specialty board. Fill only if 'Pursuing Certification (If Not Board Certified) - No' is 'Yes'.

Check this box if, after answering 'No' to pursuing certification, you DO NOT have postgraduate training sufficient to meet the requirements of a specialty board. Fill only if 'Pursuing Certification (If Not Board Certified) - No' is 'Yes'.

Check this box if you are not currently board certified and you are pursuing board certification.

Check this box if you are not currently board certified and you are not pursuing board certification.

Check this box if any restrictions have ever been placed on your liability (malpractice) insurance.

Check this box if no restrictions have ever been placed on your liability (malpractice) insurance.

Check this box if you have ever had an insurance carrier add a surcharge to your malpractice policy or increase your deductible.

Check this box if you have never had an insurance carrier add a surcharge to your malpractice policy and your deductible has never been increased.

Check this box if you have ever received a notice of claim or have been a defendant in a medical malpractice suit arising out of or in connection with your individual professional services.

Check this box if you have never received a notice of claim and have never been a defendant in a medical malpractice suit arising out of or in connection with your individual professional services.

Check this box if you are aware of any notice of claims against another person or entity arising out of or in connection with your individual professional services.

Check this box if you are not aware of any notice of claims against another person or entity arising out of or in connection with your individual professional services.

Check this box if, in the past 10 years, you or your malpractice carrier or any other person/entity made an out-of-court settlement or paid a judgment on a professional liability claim on your behalf or on behalf of any other person/entity arising out of or in connection with your professional services.

Check this box if, in the past 10 years, neither you nor your malpractice carrier nor any other person/entity made an out-of-court settlement or paid a judgment on a professional liability claim on your behalf or on behalf of any other person/entity arising out of or in connection with your professional services.

Check this box if you have ever had your clinical privileges or employment at any hospital or health care facility limited, restricted, suspended, revoked, withdrawn (involuntarily or voluntarily), not renewed, made subject to probationary conditions, otherwise adversely affected, or if such proceedings are currently pending.

Check this box if you have never had your clinical privileges or employment at any hospital or health care facility limited, restricted, suspended, revoked, withdrawn, not renewed, made subject to probationary conditions, otherwise adversely affected, and there are no such proceedings currently pending.

Check this box if you have ever had a request for any specific clinical privilege(s) denied as a result of disciplinary action, or granted only with stated limitations, or if there are such proceedings currently pending.

Check this box if you have never had a request for specific clinical privileges denied or granted only with stated limitations and there are no such proceedings currently pending.

Check this box if you have ever withdrawn an application to any healthcare entity.

Check this box if you have never withdrawn an application to any healthcare entity.

Check this box if you have ever voluntarily not renewed, surrendered, or modified your privileges or resigned from medical staff membership (moving out of state or end of contract counts as an affirmative response).

Check this box if you have never voluntarily not renewed, surrendered, or modified your privileges and have not resigned from medical staff membership.

Check this box if you have ever had your medical staff membership or status at any hospital or health care facility limited, denied, suspended, revoked, not renewed, made subject to probationary conditions, otherwise adversely affected, or if any such proceedings are currently pending.

Check this box if you have never had your medical staff membership or status limited, denied, suspended, revoked, not renewed, made subject to probationary conditions, otherwise adversely affected, and there are no such proceedings currently pending.

Check this box if there is currently pending litigation, an investigation, or a disciplinary proceeding against you related to privileges, licensure, DEA or other criminal/administrative matters, Medicare/Medicaid/QIO sanctions, or any civil matter initiated by the government.

Check this box if there is no pending litigation, investigation, or disciplinary proceeding against you regarding privileges, licensure, DEA or other criminal/administrative matters, Medicare/Medicaid/QIO sanctions, or any civil matter initiated by the government.

Check this box if you have ever been denied membership or renewal, reprimanded, censured, suspended, revoked, placed on probation, or otherwise sanctioned by any health care organization (including hospitals or other health care facilities) based on professional competence.

Check this box if you have never been denied membership or renewal, reprimanded, censured, suspended, revoked, placed on probation, or otherwise sanctioned by any health care organization based on professional competence.

Check this box if you have ever been denied membership or renewal, reprimanded, censured, suspended, revoked, placed on probation or otherwise sanctioned by HMOs, PPOs, PHOs, independent practitioner associations, professional associations/societies, standards review organizations, or peer review organizations based on professional competence.

Check this box if you have never been denied membership or renewal, reprimanded, censured, suspended, revoked, placed on probation or otherwise sanctioned by the listed organizations based on professional competence.

Check this box if you have ever been excluded, suspended, or otherwise sanctioned by Medicare or Medicaid, or if any such exclusion/suspension proceedings are currently pending against you.

Check this box if you have never been excluded, suspended, or otherwise sanctioned by Medicare or Medicaid and there are no such proceedings currently pending against you.

Check this box if you have ever been disciplined by a professional society or voluntarily resigned from a professional society while allegations were pending.

Check this box if you have never been disciplined by a professional society and have not resigned from one while allegations were pending.

Check this box if you have ever been convicted in a criminal proceeding, been subject to an adverse government agency administrative decision (including QIO, Medicare and/or Medicaid sanctions), been subject to an adverse decision in civil litigation brought by a government agency, entered a plea of nolo contendere, or been subject to an adverse settlement in any such proceeding.

Check this box if you have never been convicted in a criminal proceeding, nor been subject to any adverse government agency administrative decision, adverse government litigation decision, nolo contendere plea, or adverse settlement as described in Question 25.

Check this box if you have ever been convicted of any criminal offense (including motor vehicle offenses but not minor traffic or parking violations) or if any such criminal proceedings are currently pending against you.

Check this box if you have never been convicted of any criminal offense and there are no criminal proceedings currently pending against you.

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 have been found guilty in a proceeding that investigated substance abuse.

Check this box if you have not been found guilty in any proceeding investigating substance abuse.

Check this box if you are not physically and mentally able to perform all the essential functions or services necessary to exercise the privileges or services applied for, with or without reasonable accommodations; if selected, explain completely on a separate sheet of paper as instructed.

Check this box if you are physically and mentally able to perform all the essential functions or services necessary to exercise the privileges or services applied for, with or without reasonable accommodations.

Check this box if you are able to perform the functions described in Question 30 without significant risk of injury to yourself or others.

Check this box if you are not able to perform the functions described in Question 30 without significant risk of injury to yourself or others.

Check this box if you have ever practiced medicine without liability (malpractice) insurance coverage.

Check this box if you have never practiced medicine without liability (malpractice) insurance coverage.

Check this box if you have ever been denied professional liability insurance, had a policy canceled, or been denied renewal.

Check this box if you have never been denied professional liability insurance, had a policy canceled, and have never been denied renewal.

Enter the full name of the hospital or institution for your second hospital affiliation.

Enter the street address (including suite or building number if applicable) for this institution.

Enter the city, state, and ZIP code for the institution's address.

Enter the primary telephone number for this institution.

Enter the fax number for this institution, if available.

Enter your position or staff category (for example, Attending, Resident, Fellow, Consultant) at this institution.

Enter the department or clinical service in which you worked at this institution.

Enter the name of the department chief or supervising physician for the department during your time there.

Enter the start date of your affiliation at this institution.

Enter the end date of your affiliation at this institution.

Enter the full name of the second prior insurance carrier that provided coverage.

Enter the carrier's street address for the second prior insurance carrier (street, suite or PO box).

Enter the city, state and ZIP code for the second prior insurance carrier's address.

Enter any institution, employer, or affiliation associated with this second prior insurance carrier entry.

Enter the primary phone number for the second prior insurance carrier.

Enter the fax number for the second prior insurance carrier, if available.

Enter the policy number assigned by the second prior insurance carrier for this coverage.

Enter the start date of the coverage period provided by the second prior insurance carrier.

Enter the end date of the coverage period provided by the second prior insurance carrier.

Enter the incident limit amount for the second prior insurance carrier's policy.

Enter the aggregate limit amount for the second prior insurance carrier's policy.

Enter the first (given) name of your second professional reference.

Enter the last (family) name of your second professional reference.

Enter the academic or professional degree(s) (for example MD, DO, DMD) held by your second reference.

Enter the clinical specialty or professional discipline of your second reference.

Enter the professional email address for your second reference.

Enter the primary phone number (office or mobile) for your second reference, including area code.

Enter the fax number for your second reference, if available.

Enter the full street mailing address for your second professional reference.

Enter the city, state and ZIP or postal code for your second reference's address.

Describe briefly in what capacity this individual has observed or been responsible for your clinical abilities.

Enter the full name of the college or university for your second professional/graduate education.

Enter the degree or credential awarded for this program (for example, M.A., Ph.D., J.D.).

Enter the institution's full mailing address, including street address.

Enter the date you began attending this institution for the listed program.

Enter the date you stopped attending or completed coursework for this program.

Enter the date your degree was conferred or you graduated from this program.

Enter the country where the institution is located.

Enter the city, state/province, and postal/ZIP code for the institution.

Enter the name of the institution where you completed your second residency.

Enter the full street address of the institution for your second residency (include city, state and ZIP if applicable).

Enter the start date of attendance for the second residency.

Enter the end date of attendance for the second residency.

Enter the specialty or program area for the second residency.

Enter the full name of the program director for this residency.

Enter the academic degree(s) held by the program director (e.g., MD, DO).

Enter the official title or position of the program director.

Enter the primary telephone number to contact the program director.

Enter the fax number for the program director or program office.

Enter the email address for the program director or program office.

Enter the full name of the organization, facility, or employer for this second work history/professional affiliation entry.

Enter the street address (number, street, suite or unit) of the organization for this entry.

Enter the city, state and ZIP code for the organization's address.

Enter the full name of the primary contact person at this organization (for example, supervisor or credentialing contact).

Enter the primary phone number for the contact or organization, including area code and extension if applicable.

Enter the fax number for the organization or contact, including area code if applicable.

Enter the contact person's or organization's email address to be used for correspondence or verification.

Enter the job title or position you held at this organization for the listed period.

Enter the start date when you began working or affiliating with this organization.

Enter the end date when you stopped working or affiliating with this organization.

Enter the full legal name of the secondary insurance company that provided coverage.

Enter the street address for the secondary insurance carrier, including suite or PO box if applicable.

Enter the city, state and ZIP/postal code for the secondary carrier's address.

Enter the name of any institution or organization affiliated with this secondary insurance carrier, if applicable.

Enter the primary phone number for the secondary insurance carrier.

Enter the fax number for the secondary insurance carrier, if applicable.

Enter the policy or contract number assigned to your coverage by the secondary insurer.

Enter the start date of coverage provided by this secondary insurance carrier.

Enter the end date of coverage provided by this secondary insurance carrier.

Enter the per-incident coverage amount provided by the secondary insurance carrier.

Enter the aggregate coverage amount provided by the secondary insurance carrier.

Enter the name of the secondary medical specialty to which this board certification applies.

Enter the board certification number assigned for this secondary specialty.

Enter the date the board certification was issued for this secondary specialty.

Enter the date the board certification for this secondary specialty expires. Fill only if 'Secondary - Lifetime: No' is 'Yes'.

Enter the full name of the certifying specialty board that granted the certification.

Check this box if the secondary specialty board certification is a lifetime certification that does not expire.

Check this box if the secondary specialty board certification is not a lifetime certification and therefore has an expiration date.

Enter the date on which you signed this form.

Enter the name of the hospital or institution for your third listed affiliation.

Enter the street address (including suite or building number if applicable) for this institution.

Enter the city, state and ZIP code for this institution.

Enter the primary phone number for this institution, including area code.

Enter the fax number for this institution.

Enter the position or staff category you held at this institution (for example, Attending, Resident, Consultant).

Enter the department or service within the institution where you worked.

Enter the name of the department chief or immediate supervisor for your department at this institution.

Enter the start date when your affiliation at this institution began.

Enter the end date when your affiliation at this institution ended or write the current/end status.

Enter the third professional reference's given (first) name.

Enter the third professional reference's family (last) name.

Enter the reference's professional or academic degree(s) (for example MD, DO, DMD, PhD) if applicable.

Enter the clinical or professional specialty of the third reference.

Enter the third reference's email address (this field is required).

Enter the primary phone number where the third reference can be reached.

Enter the third reference's fax number (this field is required).

Enter the street address for the third reference, including suite or department if applicable.

Enter the city, state and ZIP/postal code for the third reference's address.

Briefly describe in what capacity the third reference has observed your clinical abilities (for example, supervisor, program director, colleague).

Enter the full name of the college or university attended for this third professional/graduate education entry.

Enter the degree, diploma, or certificate awarded for this program (for example: M.S., J.D., Ph.D.).

Provide the street address of the college or university, including building, suite, or PO box if applicable.

Enter the start date when you began attending this program.

Enter the end date when you stopped attending this program or the expected completion date.

Enter the date you graduated or completed the program.

Enter the city, state/province and postal code for the college or university.

Enter the country where the college or university is located.

Enter the full name of the organization for the third work history/professional affiliation entry.

Enter the street address (including suite or unit, if applicable) for the organization in this third entry.

Enter the city, state and ZIP code for the organization's address in this third entry.

Enter the full name of the primary contact person at the organization for this third entry.

Enter the main phone number for the contact or organization for this third entry, including area code and extension if applicable.

Enter the fax number for the contact or organization for this third entry, if available.

Enter the email address for the contact person or organization for this third work history entry.

Enter the job title or position you held at the organization for this third entry.

Enter the start date of your employment or affiliation at this organization for the third entry.

Enter the end date of your employment or affiliation at this organization for the third entry.

Enter the full name of the undergraduate college or university you attended.

Enter the degree awarded or expected for this undergraduate program (for example B.A., B.S., or specific degree title).

Enter the street address or P.O. Box of the college or university.

Enter the date when you began attending this undergraduate institution.

Enter the date when you stopped attending this undergraduate institution.

Enter the date you graduated or expect to graduate from this undergraduate program.

Enter the country where the college or university is located.

Enter the city, state/province, and postal/ZIP code for the institution.

Check this box if you are not a U.S. citizen and you are eligible to work lawfully in the United States. Fill only if 'Citizenship' is not 'US Citizen'.

Check this box if you are not a U.S. citizen and you are not eligible to work lawfully in the United States. Fill only if 'Citizenship' is not 'US Citizen'.

Check this box if you currently hold a J-1 visa. Fill only if 'Citizenship', 'Eligible to work lawfully in the United States — Yes' is not 'US Citizen' and all fields selection.

Check this box if you currently hold an H-1B visa. Fill only if 'Citizenship', 'Eligible to work lawfully in the United States — Yes' is not 'US Citizen' and all fields selection.

Check this box if you are a lawful permanent resident (Green Card holder). Fill only if 'Citizenship', 'Eligible to work lawfully in the United States — Yes' is not 'US Citizen' and all fields selection.