Risk Management Risk Management "*" indicates required fields FacebookThis field is for validation purposes and should be left unchanged.This field is hidden when viewing the formFirst NameThis field is hidden when viewing the formLast NameThis field is hidden when viewing the formEmail* This field is hidden when viewing the formToday's Date* MM slash DD slash YYYY Select Category*Select CategoryCertified Registered Nurse AnesthetistNurseNurse PractionerPhysicianPhysician AssistantHave you ever had a license to practice (including medical, DEA andcontrolled substance registrations) in any district refused, denied,suspended, revoked, restricted, placed on probation, been subject toa reprimand or voluntarily surrendered?* Yes No Tell us more*Have you ever been denied by or withdrawn an application from any licensing board?* Yes No Tell us more*Have you ever withdrawn an application for clinical privileges?* Yes No Tell us more*Have your clinical privileges ever been denied, suspended, revoked,restricted, or placed under any other disciplinary action?* Yes No Tell us more*Have you ever been terminated or asked to leave a place ofemployment or locum tenens assignment?* Yes No Tell us more*Have you ever been convicted of a felony or misdemeanor or are youcurrently charged with any alleged criminal activity?* Yes No Tell us more*Have you ever been or are you currently disciplined, sanctioned orunder investigation by Medicare or Medicaid?* Yes No Tell us more*Is there anything that would prevent you from being able to performthe essential functions of a locum tenens practitioner? If yes, please explain below.* Yes No Tell us more*Have you ever had professional liability insurance denied or cancelled?* Yes No Tell us more*Are you currently, or have you ever been involved directly or indirectly in a claim or suit (including dismissed) due to the rendering or failure to render professional services? Please explain the specific allegation(s) and the patient outcome(s) inthe box below.* Yes No Tell us more*Are you credentialed for prescriptive authority in your licensed state(s)?* Yes No Tell us more*Do you have full practice authority in any state?* Yes No Tell us moreAre you comfortable managing patients without onsite physician oversight?* Yes No Tell us more*Do you currently have or need a collaborating physician agreement?* Yes No Tell us more*Have you practiced under remote supervision before?* Yes No Tell us more*Do you currently have or need a supervising physician?* Yes No Tell us more*Do you have prescriptive authority in your current state(s)?* Yes No Tell us more*Are you comfortable working under direct, indirect, or remote supervision?* Yes No Tell us more*Are you currently authorized to practice without medical direction in any state?* Yes No Tell us more*Malpractice InformationHave any judgments or settlements been made against you in anyprofessional liability cases?* Yes No Tell us more*Are you aware of any circumstances which may result in a claim orsuit against you? Yes No Tell us morePlease list all current and previous professional liability insurers for the past 10 years.Policy Number:Policy Type (Occurrence or Claims Made)Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Insurance Carrier:Policy Number:Policy Type (Occurrence or Claims Made)Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Insurance Carrier:Policy Number:Policy Type (Occurrence or Claims Made)Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Insurance Carrier:Policy Number:Policy Type (Occurrence or Claims Made)Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Insurance Carrier:Policy Number:Policy Type (Occurrence or Claims Made)Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Insurance Carrier:Policy Number:Policy Type (Occurrence or Claims Made)Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Insurance Carrier:Policy Number:Policy Type (Occurrence or Claims Made)Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Release and Attestation* By checking this box, you confirm that you have reviewed and agree to HPA Healthcare’s Release and Attestation Policy.
