Pre-Qualification

Enter the states that you have an active/current license in: *

Are you Board Eligible? *

Do you have FCVS? *

Are you Board Certified? *

Do you have IMLCC? *

Has your medical license or DEA in any state been placed under any disciplinary action? *

Please provide a brief explanation *

Do you have any malpractice pending or settled? *

If yes, what were the outcomes? *

Are you currently or have you ever abused alcohol, used illegal drugs, or failed to take legally prescribed drugs in the manner prescribed? *

If yes, please provide an explanation *

Have you ever been convicted of a felony or a misdemeanor other than a minor traffic violation? *

If yes, please provide explanation *

Have you ever been the object of an administrative, civil, or criminal complaint or investigation regarding sexual misconduct? *

If yes, please provide explanation *

For credentialing purposes, are you willing to provide 3 professional/peer references of colleagues with whom you have worked with directly in the last 12 months, once accepted? *

First Name *

Last Name *

Email *

Specialty *

Date *

Please attach your updated CV *

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