CA California Participating Physician Application free printable template

CONFIDENTIAL/PROPRIETARY California Participating Physician Application Addendum B Professional Liability Action Explanation This Addendum is submitted to herein this Healthcare Organization 1. Please complete this form for each pending settled or otherwise concluded professional liability lawsuit or arbitration filed and served against you in which you were named a party in the past seven 7 years whether the lawsuit or arbitration is pending settled or otherwise concluded and whether or not...

• Who needs a California Participating Physician Application Form?
• Is California Physician Application Form accompanied by other forms?
• • When is current California Participating Physician Application Form due?
  • What information should be provided on California Participating Physician Application Form?
  • Where do I send California Participating Physician Application Form?

Who needs a California Participating Physician Application Form?

A medical specialist willing to apply for a position at a healthcare organization in the State o f California should inform such an organization by submitting a special application package. Besides of the CV and the licenses and various certificates, this package must also contain a very important document — a Participating Physician Application Form. The information provided on this form will help the accepting healthcare organization to investigate the applicant’s educational and professional background, provided references and consider them as a candidate for the vacant position.

Is California Physician Application Form accompanied by other forms?

As it has been mentioned above, there is a need to submit a whole package of documents which includes the following ones:

• California Participating Physician Application

• State Medical License(s)

• DEA Certificate

• Board Certification (if applicable) 

• Face Sheet of Professional Liability Policy or Certification

• Curriculum Vitae

• EC FMG (if applicable)

When is current California Participating Physician Application Form due?

The submission of the form does not imply following a standard deadline, as it can be filed when the need arises and until the applications are being accepted by the accepting healthcare organization.

What information should be provided on California Participating Physician Application Form?

The completed California Participating Physician Application must clearly provide and explain such data:

• Applicant's identifying information (full name, birthdate, citizenship, address, etc.)

• Practice information (name, specialty, address and contact information)

• Premedical education (college or university, obtained degree, date of graduation)

• Medical/professional information (educational institution, obtained degree, dates of studies, address)

• Internship/PGI (institution, specialty, address)

• Residences/ fellowships

• Board certification and other certifications

• Medical licenses and registrations

• Professional liability

• Current and previous affiliations

• Peer references

• Work history records

There is also a need to answer a list of attestation questions at the end.

Where do I send California Participating Physician Application Form?

The full package of previously listed documents and the California Participating Physician Application should be directed to the accepting healthcare organization.

 

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