Provider Registration

PERSONAL INFORMATION

First Name*

Last Name*

Phone*

Street Address*

City*

Zip Code*

State*

Email*

Marital Status*

Date of Birth*

Place of Birth

Social Security Number

EDUCATION INFORMATION

Medical School

Year of Completion

Specialty

Residency

Year of Completion

Fellowship

Year of Completion

Undergraduate Program

Graduate Program

Do you have an active DEA License?*

Yes
No
N/A

Are you board certified?*

Yes
No
N/A

State(s) Licensed*

State of Original License*

Licenses Pending

Do you carry your own malpractice insurance?*

Yes
No

CERTIFICATIONS

BLS

Yes
No

ACLS

Yes
No

PALS

Yes
No

NALS

Yes
No

Other

Yes
No

DESIRED WORK SITUATION

Describe your ideal workplace facility

Desired Shifts

What position(s) are you interested in?*

Permanent Position
Full-time Locums
Part-time Locums

When is your next availability?

What is your preferred length of assignment?

What is the maximum distance you are willing to drive for an assignment?

If you answer “yes” to any of the following, please provide complete details.

DO YOU HAVE ANY PHYSICAL CONDITIONS THAT MAY LIMIT OR HINDER YOUR PERFORMANCE IN THE POSITION FOR WHICH YOU ARE APPLYING?*

Yes
No

Explanation

HAVE YOU EVER BEEN CONVICTED OF A FELONY, A MISDEMEANOR, OR CRIME OTHER THAN A TRAFFIC VIOLATION?*

Yes
No

Explanation

HAVE YOUR PRIVILEGES AT ANY HEALTHCARE FACILITY EVER BEEN VOLUNTARILY OR INVOLUNTARILY RELINQUISHED, DENIED, OR SUSPENDED?*

Yes
No

Explanation

HAVE YOU EVER BEEN THE SUBJECT OF DISCIPLINARY PROCEEDINGS AT ANY HEALTHCARE FACILITY?*

Yes
No

Explanation

HAS YOUR LICENSE OR CERTIFICATION IN ANY STATE EVER BEEN VOLUNTARILY OR INVOLUNTARILY RELINQUISHED, SUSPENDED, OR TERMINATED?*

Yes
No

Explanation

HAVE YOU EVER BEEN THE SUBJECT OF DISCIPLINARY PROCEEDINGS OR INVESTIGATION BY ANY STATE LICENSURE BOARD?*

Yes
No

Explanation

HAVE YOU EVER BEEN SUSPENDED, TERMINATED, SANCTIONED, OR OTHERWISE RESTRICTED FROM ANY HEALTH INSURANCE PROGRAM?*

Yes
No

Explanation

HAVE YOU EVER BEEN NAMED IN, OR HAD ANY PAST/PENDING JUDGEMENTS MADE AGAINST YOU IN A PROFESSIONAL MALPRACTICE LIABILITY CASE?*

Yes
No

Explanation

DOCUMENT UPLOAD

Choose File

Please upload a document or zipped folder containing the following, if applicable: Curriculum Vitae or resume, All state licenses, DEA certificate, All certificates from medical school, internship, residency and Board Certification, Proof of certification of BLS, ACLS, PALS and/or NALS. Please also include three letters of reference, a recent photo, health status statement, and a copy of your driver’s license. If you do not have all of this information, please include as much as possible. You may also mail or fax the information. Files must be less than 5 MB. Allowed file types: zip pdf doc docx rtf.

*

Agree *

The facts set forth in this application for job placement with Radar Healthcare Providers, Inc. are true and complete. False statements on this application shall be considered sufficient cause for dismissal. Radar Healthcare Providers, Inc. and its representatives are hereby authorized to make any investigations of my personal and professional history through any agency or bureau necessary, including verification background checks and E-verify. Radar Healthcare Providers, Inc. is also authorized to investigate my ability, employment records or character through inquires to individuals and/or employers mentioned in this application. I hereby agree that this authorization and appointment shall be valid until revoked by me in written revocation delivered to Radar Healthcare Providers, Inc. I hereby release Radar Healthcare Providers, Inc. and the person(s) to whom the inquiry is made from any and all claims and liability growing out of such inquiries, and consent to the release of such information.

Phone

This field is for validation purposes and should be left unchanged.

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PERSONAL INFORMATION

EDUCATION INFORMATION

CERTIFICATIONS

DESIRED WORK SITUATION

DOCUMENT UPLOAD

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