Provider Application Date of Application:Anticipated Start Date:Applying for: Full-Time Part-Time Requesting Participation as a: PCP Specialist Both Specialty:Second Specialty:Provider Type: MD DO DPM NP RN Other When would you be available to begin work?Can you do shift/weekend work?YesNoSalary Expectations: (Please provide range)Have you ever worked for this company?YesNoIf so, when?Do you have any relatives or friends who work for the company?YesNoIf yes, give name(s) and relationship(s)How did you hear about Doctors on Call?IndeedLinkedInZip RecruiterCompany SiteOtherPersonal DataName: First Middle Last Title Address:City:State:Zip:Phone:Cell:Email: Languages Spoken:Medical QualificationEducation Completed in the US:YesNoECFMG#:Degree Completed at:Type of Degree:Are You Board Certified: Yes No Certificate #Certificate Date:Expiration Date:Re-certification Date:Expiration Date:If Yes, Indicate Month/Year:Specialty:Second Specialty:YesNoCertificate #Certificate Date:Expiration Date:Re-certificate Date:Expiration Date:I do not plan to sit for board because (CAQH asks this question):Work EligibilityAre you legally eligible to be employed in the United States?YesNoWould you need sponsorship to work?YesNoLicensure Present and ExpiredList all states where you are currently licensed or have previously been licensed or where you have currently or previously applied for licensure.StateDate Issued:License Number:Expiration Date:StateDate Issued:License Number:Expiration Date:Credentialing InformationAre you registered with CAQH?YesNoCAQH Number:Username:Password:PECO’s number:Username:Password:Medicare ID#:Medicaid ID#:Individual NPI#:DEA#: Δ
