Get the free Physician Screening Form

This form is used by employees or spouses of OLD NATIONAL BANK to provide personal health information for participation in the Deaconess Clinic Wellness Solutions Wellness Program. It includes sections for personal details, health history, and authorization for information release, ensuring confidentiality while collecting necessary health metrics.

How to fill out physician screening form

How to fill out physician screening form

1. Obtain a copy of the physician screening form from your healthcare provider or their website.
2. Fill in your personal information, including full name, date of birth, and contact details.
3. Provide relevant medical history, including any chronic conditions, allergies, and medications you are currently taking.
4. List any previous surgeries or significant medical procedures you've undergone.
5. Answer questions related to family medical history, particularly hereditary illnesses.
6. Complete sections regarding lifestyle habits such as smoking, alcohol consumption, and exercise frequency.
7. Sign and date the form to confirm that all information provided is accurate.

Who needs physician screening form?

1. Individuals seeking a medical evaluation or assessment.
2. Patients applying for certain insurance policies.
3. Participants in clinical trials or research studies.
4. Individuals requiring clearance for employment or sports activity.

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What is physician screening form?

The physician screening form is a document used to gather necessary information about a physician's qualifications, medical history, and performance for evaluation and compliance purposes.

Who is required to file physician screening form?

Typically, healthcare providers, including hospitals and clinics, are required to file the physician screening form for their employed or affiliated physicians.

How to fill out physician screening form?

To fill out the physician screening form, a physician must provide personal information, educational background, licenses, certifications, malpractice history, and any disciplinary actions.

What is the purpose of physician screening form?

The purpose of the physician screening form is to ensure that physicians meet the necessary standards for practice, maintain compliance with regulations, and safeguard patient safety.

What information must be reported on physician screening form?

Information that must be reported includes the physician's name, contact details, medical licenses, education, training, board certifications, work history, and any criminal or malpractice history.