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Hospital Credentialing Purchase Form

To Begin the process please enter your information below:

Credit Card First Name:  
Credit Card Last Name:
 Billing Address:
City:  
State:
Zip:
Country:

Phone Number:

Credit Card Information
Card Number:
Exp. Date:

Personal Information

Type of Degree     
MD 
DO
OD 
DDS 
DMD
DPM
DVM
NP
PA
RN
LPN
Other

Hospitals where you are to be Privileged / Credentialed
Name of Hospital City/State Credentialing Contact Type of Privilege
Will you be supplying the applications or will MedLicense.com need to contact the credentialing office of each Facility to obtain?
Full Legal Name
Maiden Name
Name on Birth Certificate
Explanation of Change (If any)
US Social Security Number
Mailing Address 

 
Employer's Name

Work Address

Contact Phone Number

Fax Number

Email Address

Work Phone Number

Date of Birth (MM/DD/YY)
Place of Birth
  Male Female USA Citizen? Yes No
   
List the names and locations of all colleges or universities attended where pre-professional, post-secondary instruction was received:
High School  
City & State
Year of Graduation
Pre-Med College/University Name
City & State
Country
Attendance (MM/YY-MM/YY)
Degree None   BA BS MA    MS   Other  

(If other then: )

 
   
Pre-Med College/University  # 2
City & State
Country
Zip/Postal Code
Attendance (MM/YY-MM/YY)
Degree None   BA BS MA    MS   Other  

(If other then: )

 
Pre-Med College/University Name # 3
City & State
Country
Zip/Postal Code
Attendance (MM/YY-MM/YY)
Degree None   BA BS MA    MS   Other  

(If other then: )

 

 

Complete Name of Medical School (If Physician): 

   (Do Not Abbreviate)

City, State, Country, and Zip Code:                     

Dates of Attendance: (MM/YY-MM/YY)

Exact Date of Graduation: (MM/DD/YY)

//

Degree: None  MD DO MD/PhD  MBBS

Did you ever take a leave(s) of absence or break(s) from your medical education?

Yes No
Where you ever placed on probation? Yes No
Were you ever disciplined or placed under investigation? Yes No
Were any negative reports ever filed against you? Yes No
Were any limitations or special requirements imposed on you because of academic, incompetence, disciplinary problems or for any other reason? Yes No
Please explain any "Yes" responses from above:

Did you attend a Fifth Pathway program?

Yes No
Did you complete any clinical clerkship in a country other than where your medical school is located? Yes No
Which examination(s) did you take?
USMLE    FLEX            NBME      NBOME     
SPEX       State Exam    LMCC       

Please provides Dates & States if known of Each Part:

Part/Step 1
Part/Step 2
Part/Step 3
Have you ever been licensed to practice medicine in any state, territory, province, country, or U.S. federal jurisdiction?

Yes    No

If yes then list each below:
State / Country

License Number

Date Issued    

Expiration Date

Status of License

State / Country

License Number

Date Issued    

Expiration Date  
Status of License

State / Country

License Number

Date Issued    

Expiration Date

Status of License

State / Country

License Number

Date Issued  

Expiration Date

Status of License

State / Country

License Number

Date Issued  

Expiration Date

Status of License

State / Country

License Number

Date Issued    

Expiration Date

Status of License

State / Country

License Number

Date Issued  

Expiration Date

Status of License

   
 

Postgraduate Medical Education (Internship/Residency/Fellowship)

 
Complete Name of Hospital where training was conducted.
City
State/Province, & Country
Type of Training (check all that apply)

Internship Residency Fellowship Research
Name of Program/Training
From - To (MM/YY-MM/YY)

Successfully Completed?

Yes No In Progress

Postgraduate Medical Education # 2

 
Complete Name of Hospital where training was conducted.
City
State/Province, & Country
Type of Training (check all that apply)

Internship Residency Fellowship Research
Name of Program/Training
From - To (MM/YY-MM/YY)

Successfully Completed?

Yes No In Progress
 

Postgraduate Medical Education #3

 
Complete Name of Hospital where training was conducted.
City
State/Province, & Country
Type of Training (check all that apply)

Internship Residency Fellowship Research
Name of Program/Training
From - To (MM/YY-MM/YY)

Successfully Completed?

Yes No In Progress

Questions

Have you served in the US Armed Forces?

Yes No
If Yes, please provide Rank & Branch
Are you required to pay Child Support?

Yes No
Have you ever withdrawn from, or been suspended, dismissed or expelled from a medical school or postgraduate training program OR have you ever taken leave of absence from such a school or program? 

Yes No
Have you ever been charged with, or been found to have committed, unprofessional conduct, professional incompetence, gross negligence, or repeated negligent acts or malpractice by any medical licensing board, other agency, or hospital? Yes No
Have you ever been investigated and or disciplined by a State Medical Board? Yes No
Have you ever been investigated and or disciplined by a Hospital or Healthcare Institution? Yes No
Have you ever been denied a license by a State Medical Board or DEA? Yes No
Do you have any condition which in any way impairs or limits your ability to practice medicine with reasonable skill and safety? Yes No
Have you ever been convicted of, or pled nolo contendere to, ANY violation  of any local, state, or federal law of any state, territory, country, or U.S. federal jurisdiction? Yes No
Have you ever been arrested? Yes No
Are you currently registered with the DEA? Yes No
If you are registered with the DEA, provide the number and state of issue:  

 
Have you ever had any malpractice suits filed against you? Yes No
Have you ever voluntarily surrendered a controlled substance registration, DEA #, or Medicare/Medicaid Number? Yes No
To you knowledge, are you the subject of an investigation by any licensing Board or agency as of the date of this application? Yes No
Have you ever had any restrictions as a Medicaid or Medicare provider? Yes No
Have you ever defaulted on a state or federally funded and/or guaranteed school loan? Yes No
Have you ever defaulted on child support payments? Yes No
 
ECFMG Number

Date Issued (MM/DD/YY)

Physical Description
Height Feet Inches Weight
Race  Eye Color
Hair Color   
Physical Marks

Yes No

If yes then describe them below:

Specialty Certification

Specialty

Board Certified

Yes  No      If no:  

Are you qualified to sit for the examination? Yes  No  
Board Name

Initial Certification Date

Date of Most Recent Certification

Date Qualified

Qualification Expires

 Subspecialty

 Subspecialty

Reference # 1
Name                             MD DO
Mailing Address
Phone Number                Fax Number

Reference # 2
Name                             MD DO
Mailing Address
Phone Number                Fax Number

Reference # 3
Name                             MD DO
Mailing Address
Phone Number                Fax Number
Name of Future Supervising Physician #1 (if PA, NP, or RN)

Name of Future Supervising Physician #2 (if PA, NP, or RN)

 

USA and International Graduates - Hospital Privileges

 
Hospital

City, State

Dates of Privileges

   
Hospital

City, State

Dates of Privileges

   
Hospital

City, State

Dates of Privileges

   
Hospital

City, State

Dates of Privileges

How did you hear about us?  

Agree to terms of release

MedLicense.com will ship the packet to you via USPS Priority Mail. If you prefer another shipping method please make your selection: Fedex Yes-$15.00 or   Own Account $0.00:
UPS Yes - $18.00 or   Own Account $0.00
USPS Express Mail Yes - $15.00 
Would you like to add DEA Registration Services for $60.00? (Regular price is $120.00)   Yes
Would you like to add Document Storage Services for $295.00?  (Regular price is $415.00)  Yes    
Would you like to add Medicare/Medicaid Registration Services for $600.00? (Regular prices is $800.00)  Yes   
Add License / Permit AutoRenewal  Services for $150.00 ($150.00 per license/permit - per renewal period)  Yes   

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