Provider Interest Form
Sign in to Google to save your progress. Learn more
Email *
Name *
First and last name
What is your degree? *
Phone number *
What time zone do you reside in? *
Please state your specialty and any sub-specialties *
What Board Certifications do you hold? *
Please list all states where you have held or currently hold a license: *
Do you have an IMLC LOQ?  If so, what state is it held in? *
Do you have current hospital privileges in good standing? *
Have you been actively seeing patients for the past 2 years and will you be able to provide detailed activity logs (encounter dates, diagnosis, etc)? *
Do you see pediatric patients?  What ages? *
Are you maintaining CME levels of 25 per year minimum? *
What is your level of familiarity with the following software? *
Never Used
Somewhat Familiar
Familiar - Efficient
Expert - Very Familiar
Epic
Cerner
CPSI
Meditech
Zoom
Please describe your availability and how many days/hours you are hoping to work. *
Our partners sites are CMS participating facilities.  You will be enrolled in Medicare/Medicaid for this work.  Please confirm this is acceptable. *
A. Have you ever been named in a party to a medical malpractice claim whether settled, dismissed, or otherwise handled? *
B. Have you ever had a state license censured, revoked, or otherwise impinged upon by the governing body? *
C. For any hospital privileges and affiliations currently held or previously held, have those ever been censured, revoked or otherwise impinged upon by the governing body, OR have you resigned such privileges for fear of that happening? *
D. Moral Turpitude: This is defined as things like discrimination, harrasment, drug or alchohol use on the job, DUI, etc: Have you ever been accused of or arrested for issues of moral turpitdue, or anything else that would reflect poorly on the AmplifyMD or our partners?
 *
If you answered yes to questions A-D above, please explain:
Please send a copy of your CV to angela@amplifymd.com *
Required
By entering your name below you attest that this information is true and accurate: *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of tsqrdinc.com. Report Abuse
Google Forms